streamline-emr/docker/streamline-src/Modules/Insurance/Resources/views/insurance_groups/create.blade.php

@extends('layouts.main')

@push('styles')
    <link href="{{ asset('elite/bower_components/select2/select2.min.css') }}" rel="stylesheet" />
    <link href="{{ asset('elite/bower_components/bootstrap-datepicker/bootstrap-datepicker.min.css') }}" rel="stylesheet" type="text/css" />
@endpush

@section('content')

    <div class="row bg-title">
        <div class="col-lg-3 col-md-4 col-sm-4 col-xs-12">
            <h4 class="page-title">{{ __('insurance_groups.new_insurance_group') }}</h4>
        </div>
        <div class="col-lg-9 col-sm-8 col-md-8 col-xs-12">
            <ol class="breadcrumb">
                <li><a href="{{ route('home') }}">{{ __('insurance_groups.dashboard') }}</a></li>
                <li><a href="/insurance/scheme_administration">{{ __('insurance.scheme_administration') }}</a></li>
                <li><a href="/insurance_groups/">{{ __('insurance_groups.insurance_groups') }}</a></li>
                <li class="active">{{ __('insurance_groups.register') }}</li>
            </ol>
        </div>
    </div>

    @include('insurance::insurance_groups.menu')

    @include('flash::message')

    @include ('errors.list')

    <div class="panel panel-default">

        <div class="panel-body">

            {{ Form::open(['route' => 'insurance_groups.store','data-toggle'=>'validator']) }}

            <div class="row">
                <div class="col-md-6">
                    <div class="form-group">
                        {{ Form::label('name', __('insurance_groups.group_name')) }}
                        {{ Form::text('name', '', ['class' => 'form-control compulsory', 'required']) }}
                        <div class="help-block with-errors"></div>
                    </div>
        
                    <div class="form-group">
                        {{ Form::label('contact_name', __('insurance_groups.contact_name')) }}
                        {{ Form::text('contact_name', '', ['class' => 'form-control compulsory', 'required']) }}
                        <div class="help-block with-errors"></div>
                    </div>
        
                    <div class="form-group">
                        {{ Form::label('contact_number',__('insurance_groups.contact_phone_number')) }}
                        {{ Form::text('contact_number','',['class' => 'form-control compulsory','required']) }}
                        <div class="help-block with-errors"></div>
                    </div>

                    <div class="form-group">
                        {{ Form::label('group_email',__('insurance.email')) }}
                        {{ Form::email('group_email','',['class' => 'form-control compulsory']) }}
                        <div class="help-block with-errors"></div>
                    </div>
                </div>
                <div class="col-md-6">
                    <div class="form-group">
                        {{ Form::label('country_id',__('patients.country_of_origin')) }}
                        {{ Form::select('country_id', $countries, '',['class' => 'form-control', 'data-error'=>'Select the country', 'required']) }}
                        <div class="help-block with-errors"></div>
                    </div>

                    <div class="form-group">
                        {{ Form::label('last_fees_billing_date', __('insurance.date_of_last_fees_billing')) }}
                        <div class="input-group">
                            {{ Form::text('last_fees_billing_date','',['class' => 'form-control','readonly','id'=>'last_fees_billing_date']) }}
                            <span class="input-group-addon"><i class="icon-calender"></i></span>
                        </div>
                        <div class="help-block with-errors"></div>
                    </div>

                    <div class="form-group">
                        {{ Form::label('last_fees_payment_date', __('insurance.date_of_last_fees_payment')) }}
                        <div class="input-group">
                            {{ Form::text('last_fees_payment_date','',['class' => 'form-control','readonly','id'=>'last_fees_payment_date']) }}
                            <span class="input-group-addon"><i class="icon-calender"></i></span>
                        </div>
                        <div class="help-block with-errors"></div>
                    </div>

                    <div class="form-group">
                        {{ Form::label('risk_id',__('insurance.risk')) }}
                        {{ Form::select('risk_id[]', $chi_risks, '',['class' => 'form-control compulsory risk_id', 'data-error'=>'Select the risk', 'required', 'multiple']) }}
                        <div class="help-block with-errors"></div>
                    </div>
                </div>
            </div>

            {{ Form::button(__('insurance_groups.submit'),['type'=>'submit','class'=>'btn btn-success waves-effect waves-light m-r-10']) }}
            {{ Form::button(__('insurance_groups.cancel'),['type'=>'reset','class'=>'btn btn-default waves-effect waves-light']) }}

            {{ Form::close() }}
        </div>
    </div>
@endsection

@push('scripts')
    <script src="{{ asset('elite/js/validator.js') }}"></script>
    <script src="{{ asset('elite/js/mask.js') }}"></script>
    <script src="{{ asset('elite/bower_components/bootstrap-datepicker/bootstrap-datepicker.min.js') }}"></script>
    <script src="{{ asset('elite/bower_components/select2/select2.min.js') }}"></script>
    <script type="text/javascript">
        $('.risk_id').select2({
            placeholder: "Select"
        });

        $('#last_fees_billing_date,#last_fees_payment_date').datepicker({
            autoclose: true,
            todayHighlight: true,
            format: 'dd-mm-yyyy'
        });
    </script>
@endpush