@include('flash::message')
{{ Form::open(['route' => 'patients.select', 'method' => 'ANY', 'role' => 'search']) }}
{{ Form::label('number', __('patients.patient_number')) }}
{{ Form::text('number', '', ['class' => 'form-control typeahead', 'placeholder' => 'Patient number', 'autocomplete' => 'off', 'spellcheck' => false]) }}
{{ Form::label('first_name', __('patients.first_name')) }}
{{ Form::text('first_name', '', ['class' => 'form-control typeahead', 'placeholder' => 'First name', 'autocomplete' => 'off', 'spellcheck' => false]) }}
{{ Form::label('last_name', __('patients.last_name')) }}
{{ Form::text('last_name', '', ['class' => 'form-control typeahead', 'placeholder' => 'Last name', 'autocomplete' => 'off', 'spellcheck' => false]) }}
{{ Form::label('national_id', __('patients.national_id')) }}
{{ Form::text('national_id', '', ['class' => 'form-control typeahead', 'placeholder' => 'National ID', 'autocomplete' => 'off', 'spellcheck' => false]) }}
@if(is_chi_enabled())
{{ Form::label('insurance_group', __('patients.insurance_group')) }}
{{ Form::text('insurance_group', '', ['class' => 'form-control typeahead', 'placeholder' => 'Insurance Group', 'autocomplete' => 'off', 'spellcheck' => false]) }}
@endif
{{ Form::label('patient_category', __('patients.patient_category')) }}
{{ Form::text('patient_category', '', ['class' => 'form-control typeahead', 'placeholder' => 'Patient Category', 'autocomplete' => 'off', 'spellcheck' => false]) }}
{{ Form::label('subcounty', __('patients.sub_county')) }}
{{ Form::text('subcounty', '', ['class' => 'form-control typeahead', 'placeholder' => 'SubCounty', 'autocomplete' => 'off', 'spellcheck' => false]) }}
{{ Form::label('parish', __('patients.parish')) }}
{{ Form::text('parish', '', ['class' => 'form-control typeahead', 'placeholder' => 'Parish', 'autocomplete' => 'off', 'spellcheck' => false]) }}
{{ Form::label('village', __('patients.village')) }}
{{ Form::text('village', '', ['class' => 'form-control typeahead', 'placeholder' => 'Village', 'autocomplete' => 'off', 'spellcheck' => false]) }}
{{ Form::label('phone_number', __('patients.phone_number')) }}
{{ Form::text('phone_number', '', ['class' => 'form-control typeahead', 'placeholder' => __('patients.phone_number'), 'autocomplete' => 'off', 'spellcheck' => false]) }}