Server : Apache System : Linux server2.corals.io 4.18.0-348.2.1.el8_5.x86_64 #1 SMP Mon Nov 15 09:17:08 EST 2021 x86_64 User : corals ( 1002) PHP Version : 7.4.33 Disable Function : exec,passthru,shell_exec,system Directory : /home/corals/clinic.corals.io/storage/framework/views/ |
<div class="row gx-10 mb-5">
<div class="col-md-6 mb-5">
<?php echo e(Form::label('firstName',__('messages.patient.first_name').':' ,['class' => 'form-label fs-6 fw-bolder text-gray-700 mb-3 required'])); ?>
<?php echo e(Form::text('first_name',!empty($patient->user) ? $patient->user->first_name : null,['class' => 'form-control form-control-solid','placeholder' => 'First Name','required'])); ?>
</div>
<div class="col-md-6 mb-5">
<?php echo e(Form::label('lastName',__('messages.patient.last_name').':' ,['class' => 'form-label fs-6 fw-bolder text-gray-700 mb-3 required'])); ?>
<?php echo e(Form::text('last_name',!empty($patient->user) ? $patient->user->last_name : null,['class' => 'form-control form-control-solid','placeholder' => 'Last Name','required'])); ?>
</div>
<div class="col-md-6 mb-5">
<?php echo e(Form::label('patientUniqueId',__('messages.patient.patient_unique_id').':' ,['class' => 'form-label fs-6 fw-bolder text-gray-700 mb-3 required'])); ?>
<?php echo e(Form::text('patient_unique_id',isset($data['patientUniqueId']) ? $data['patientUniqueId'] : null,['class' => 'form-control form-control-solid','required','maxLength' => '8','readonly'])); ?>
</div>
<div class="col-md-6 mb-5">
<?php echo e(Form::label('email',__('messages.patient.email').':' ,['class' => 'form-label fs-6 fw-bolder text-gray-700 mb-3 required'])); ?>
<?php echo e(Form::email('email',!empty($patient->user) ? $patient->user->email : null,['class' => 'form-control form-control-solid','placeholder' => 'Email','required'])); ?>
</div>
<?php if(empty($patient)): ?>
<div class="col-md-6 mb-5">
<div class="fv-row" data-kt-password-meter="true">
<div class="mb-1">
<?php echo e(Form::label('password',__('messages.patient.password').':' ,['class' => 'form-label fs-6 fw-bolder text-gray-700 mb-3 required'])); ?>
<span data-bs-toggle="tooltip"
title="Use 8 or more characters with a mix of letters, numbers & symbols."><i
class="fa fa-question-circle"></i></span>
<div class="position-relative mb-3">
<input class="form-control form-control-lg form-control-solid"
type="password" placeholder="Password" name="password" autocomplete="off" required>
<span class="btn btn-sm btn-icon position-absolute translate-middle top-50 end-0 me-n2"
data-kt-password-meter-control="visibility">
<i class="bi bi-eye-slash fs-2"></i>
<i class="bi bi-eye fs-2 d-none"></i>
</span>
</div>
</div>
<div class="d-flex align-items-center mb-3" data-kt-password-meter-control="highlight">
<div class="flex-grow-1 bg-secondary bg-active-success rounded h-5px me-2"></div>
<div class="flex-grow-1 bg-secondary bg-active-success rounded h-5px me-2"></div>
<div class="flex-grow-1 bg-secondary bg-active-success rounded h-5px me-2"></div>
<div class="flex-grow-1 bg-secondary bg-active-success rounded h-5px"></div>
</div>
</div>
</div>
<div class="col-md-6 mb-5">
<div class="fv-row" data-kt-password-meter="true">
<div class="mb-1">
<?php echo e(Form::label('confirmPassword',__('messages.patient.confirm_password').':' ,['class' => 'form-label fs-6 fw-bolder text-gray-700 mb-3 required'])); ?>
<span data-bs-toggle="tooltip"
title="Use 8 or more characters with a mix of letters, numbers & symbols."><i
class="fa fa-question-circle"></i></span>
<div class="position-relative mb-3">
<input class="form-control form-control-lg form-control-solid"
type="password" placeholder="Password" name="password_confirmation" autocomplete="off"
required>
<span class="btn btn-sm btn-icon position-absolute translate-middle top-50 end-0 me-n2"
data-kt-password-meter-control="visibility">
<i class="bi bi-eye-slash fs-2"></i>
<i class="bi bi-eye fs-2 d-none"></i>
</span>
</div>
</div>
<div class="d-flex align-items-center mb-3" data-kt-password-meter-control="highlight">
<div class="flex-grow-1 bg-secondary bg-active-success rounded h-5px me-2"></div>
<div class="flex-grow-1 bg-secondary bg-active-success rounded h-5px me-2"></div>
<div class="flex-grow-1 bg-secondary bg-active-success rounded h-5px me-2"></div>
<div class="flex-grow-1 bg-secondary bg-active-success rounded h-5px"></div>
</div>
</div>
</div>
<?php endif; ?>
<div class="col-md-6 mb-5">
<?php echo e(Form::label('contactNo',__('messages.patient.contact_no').':' ,['class' => 'form-label fs-6 fw-bolder text-gray-700 mb-3'])); ?>
<br>
<?php echo e(Form::tel('contact',!empty($patient->user) ? $patient->user->contact : null,['class' => 'form-control form-control-solid','placeholder' => 'Contact No','onkeyup' => 'if (/\D/g.test(this.value)) this.value = this.value.replace(/\D/g,"")','id'=>'phoneNumber'])); ?>
<?php echo e(Form::hidden('region_code',!empty($patient->user) ? $patient->user->region_code : null,['id'=>'prefix_code'])); ?>
<span id="valid-msg" class="hide">✓ Valid</span>
<span id="error-msg" class="hide"></span>
</div>
<div class="col-md-6 mb-5">
<?php echo e(Form::label('gender',__('messages.patient.gender').':' ,['class' => 'form-label fs-6 fw-bolder text-gray-700 mb-3'])); ?>
<span class="form-check form-check-custom form-check-solid is-valid">
<div class="align-items-baseline">
<label class="form-label fs-6 fw-bolder text-gray-700 mr-3"><?php echo e(__('messages.patient.male')); ?></label>
<input class="form-check-input" checked type="radio" name="gender" value="1"
<?php echo e(!empty($patient->user) && $patient->user->gender === 1 ? 'checked' : ''); ?> >
<label class="form-label fs-6 fw-bolder text-gray-700 mx-3"><?php echo e(__('messages.patient.female')); ?></label>
<input class="form-check-input" type="radio" name="gender" value="2"
<?php echo e(!empty($patient->user) && $patient->user->gender === 2 ? 'checked' : ''); ?> >
</div>
</span>
</div>
<div class="col-md-6 mb-5">
<?php echo e(Form::label('dob',__('messages.patient.dob').':' ,['class' => 'form-label fs-6 fw-bolder text-gray-700 mb-3'])); ?>
<?php echo e(Form::text('dob',!empty($patient->user) ? $patient->user->dob : null,['class' => 'form-control form-control-solid','id' => 'dob', 'placeholder' => 'DOB'])); ?>
</div>
<div class="col-md-6 mb-5">
<label class="form-label fs-6 fw-bolder text-gray-700 mb-2"><?php echo e(__('messages.patient.blood_group').':'); ?></label>
<?php echo e(Form::select('blood_group', $data['bloodGroupList'] ,!empty($patient->user) ? $patient->user->blood_group : null, ['placeholder' => 'Select Blood Group','class' => 'form-select form-select-solid form-select-lg fw-bold', 'aria-label'=>"Select a Blood Group",'data-control'=>'select2'])); ?>
</div>
</div>
<div class="row">
<div class="col-lg-6">
<div class="justify-content-center">
<label class="col-form-label fw-bolder fs-6">
<span><?php echo e(__('messages.patient.profile')); ?>: </span>
<i class="fa fa-question-circle ms-1 fs-7" data-bs-toggle="tooltip"
title="Best resolution for this profile will be 150X150"
data-bs-original-title="Phone number must be active"
aria-label="Phone number must be active"></i>
</label>
</div>
<?php $styleCss = 'style'; ?>
<div class="image-input image-input-outline" data-kt-image-input="true">
<div class="image-input-wrapper w-125px h-125px" id="bgImage"
<?php echo e($styleCss); ?>="
background-image: url(<?php echo e(!empty($patient->profile) ? $patient->profile : asset('web/media/avatars/male.png')); ?>
)">
</div>
<label class="btn btn-icon btn-circle btn-active-color-primary w-25px h-25px bg-white shadow"
data-kt-image-input-action="change" data-bs-toggle="tooltip" title=""
data-bs-original-title="Change profile">
<i class="bi bi-pencil-fill fs-7">
<input type="file" name="profile" accept=".png, .jpg, .jpeg">
</i>
<input type="file" name="avatar" accept=".png, .jpg, .jpeg" id="profilePicture">
<input type="hidden" name="avatar_remove">
</label>
</div>
<div class="form-text">Allowed file types: png, jpg, jpeg.</div>
</div>
<div class="fw-bolder fs-3 rotate collapsible mb-7 mt-5" data-bs-toggle="collapse"
href="#kt_modal_add_customer_billing_info" role="button" aria-expanded="false"
aria-controls="kt_customer_view_details"><?php echo e(__('messages.patient.address_information')); ?>
</div>
<div class="d-flex col-md-6 flex-column mb-7 fv-row">
<?php echo e(Form::label('address1',__('messages.patient.address1').':' ,['class' => 'form-label fs-6 fw-bolder text-gray-700 mb-3'])); ?>
<?php echo e(Form::text('address1',!empty($patient->address) ? $patient->address->address1 : null,['class' => 'form-control form-control-solid','placeholder' => 'Address 1'])); ?>
</div>
<div class="d-flex col-md-6 flex-column mb-7 fv-row">
<?php echo e(Form::label('address2',__('messages.patient.address2').':' ,['class' => 'form-label fs-6 fw-bolder text-gray-700 mb-3'])); ?>
<?php echo e(Form::text('address2',!empty($patient->address) ? $patient->address->address2 : null,['class' => 'form-control form-control-solid','placeholder' => 'Address 2'])); ?>
</div>
<div class="d-flex col-md-6 flex-column mb-7 fv-row">
<?php echo e(Form::label('country_id',__('messages.country.country').':',['class'=>'form-label fs-6 fw-bolder text-gray-700 mb-2'])); ?>
<?php echo e(Form::select('country_id', $data['countries'] ,null, ['id' => 'countryId','data-placeholder' => 'Select Country','class' => 'form-select form-select-solid form-select-lg fw-bold', 'aria-label'=>"Select a Country",
'data-control'=>'select2'])); ?>
</div>
<div class="d-flex col-md-6 flex-column mb-7 fv-row">
<?php echo e(Form::label('state_id',__('messages.state.state').':',['class'=>'form-label fs-6 fw-bolder text-gray-700 mb-2'])); ?>
<?php echo e(Form::select('state_id', [], null, ['id' => 'stateId','class' => 'form-select form-select-solid form-select-lg fw-bold',
'data-placeholder' => 'Select State','aria-label'=>"Select State",'data-control'=>'select2'])); ?>
</div>
<div class="d-flex col-md-6 flex-column mb-7 fv-row">
<?php echo e(Form::label('city_id',__('messages.city.city').':',['class'=>'form-label fs-6 fw-bolder text-gray-700 mb-2'])); ?>
<?php echo e(Form::select('city_id', [], null, ['id' => 'cityId','class' => 'form-select form-select-solid form-select-lg fw-bold', 'data-placeholder' => 'Select State','aria-label'=>"Select City",'data-control'=>'select2'])); ?>
</div>
<div class="col-md-6 fv-row mb-7">
<?php echo e(Form::label('postalCode',__('messages.patient.postal_code').':' ,['class' => 'form-label fs-6 fw-bolder text-gray-700 mb-2'])); ?>
<?php echo e(Form::text('postal_code',!empty($patient->address) ? $patient->address->postal_code : null,['class' => 'form-control form-control-solid','placeholder' => 'Postal Code'])); ?>
</div>
<div>
<?php echo e(Form::submit(__('messages.common.save'),['class' => 'btn btn-primary me-2'])); ?>
<a href="<?php echo e(route('patients.index')); ?>" type="reset"
class="btn btn-light btn-active-light-primary"><?php echo e(__('messages.common.discard')); ?></a>
</div>
</div>
<?php /**PATH /home/corals/clinic.corals.io/resources/views/patients/fields.blade.php ENDPATH**/ ?>