{{ Form::label('firstName',__('messages.patient.first_name').':' ,['class' => 'form-label required']) }} {{ Form::text('first_name',!empty($patient->user) ? $patient->user->first_name : null,['class' => 'form-control','placeholder' => __('messages.patient.first_name'),'required']) }}

{{ Form::label('lastName',__('messages.patient.last_name').':' ,['class' => 'form-label required']) }} {{ Form::text('last_name',!empty($patient->user) ? $patient->user->last_name : null,['class' => 'form-control','placeholder' => __('messages.patient.last_name'),'required']) }}

{{ Form::label('patientUniqueId',__('messages.patient.patient_unique_id').':' ,['class' => 'form-label required']) }} {{ Form::text('patient_unique_id',isset($data['patientUniqueId']) ? $data['patientUniqueId'] : null,['class' => 'form-control','required','maxLength' => '8','readonly']) }}

{{ Form::label('email',__('messages.patient.email').':' ,['class' => 'form-label required']) }} {{ Form::email('email',!empty($patient->user) ? $patient->user->email : null,['class' => 'form-control','placeholder' => __('messages.patient.email'),'required']) }}

@if(empty($patient))

{{ Form::label('password',__('messages.patient.password').':' ,['class' => 'form-label required']) }}

{{Form::password('password',['class' => 'form-control','placeholder' => __('messages.patient.password'),'autocomplete' => 'off','required','aria-label'=>"Password",'data-toggle'=>"password"])}}

{{ Form::label('confirmPassword',__('messages.patient.confirm_password').':' ,['class' => 'form-label required']) }}

{{Form::password('password_confirmation',['class' => 'form-control','placeholder' => __('messages.user.confirm_password'),'autocomplete' => 'off','required','aria-label'=>"Password",'data-toggle'=>"password"])}}

@endif

{{ Form::label('contact', __('messages.patient.contact_no').':', ['class' => 'form-label']) }} {{ Form::tel('contact', !empty($patient->user) ? '+'.$patient->user->region_code.$patient->user->contact : null, ['class' => 'form-control', 'placeholder' => __('messages.patient.contact_no'),'onkeyup' => 'if (/\D/g.test(this.value)) this.value = this.value.replace(/\D/g,"")','id'=>'phoneNumber']) }} {{ Form::hidden('region_code',!empty($patient->user) ? $patient->user->region_code : null,['id'=>'prefix_code']) }}

{{ Form::label('gender', __('messages.staff.gender').':', ['class' => 'form-label required']) }}

user) && $patient->user->gender === 1 ? 'checked' : '' }} > {{ __('messages.staff.male') }} user) && $patient->user->gender === 2 ? 'checked' : '' }} > {{ __('messages.staff.female') }}

{{ Form::label('dob',__('messages.patient.dob').':' ,['class' => 'form-label']) }} {{ Form::text('dob',!empty($patient->user) ? $patient->user->dob : null,['class' => 'form-control patient-dob','id' => __('messages.patient.dob'), 'placeholder' => __('messages.doctor.dob')]) }}

{{ __('messages.patient.blood_group').':' }} {{ Form::select('blood_group', $data['bloodGroupList'] ,!empty($patient->user) ? $patient->user->blood_group : null, ['placeholder' => __('messages.patient.blood_group'),'class' => 'form-select io-select2', 'aria-label'=>"Select a Blood Group",'data-control'=>'select2']) }}

{{__('messages.patient.profile')}}:

{{ Form::label('address1',__('messages.patient.address1').':' ,['class' => 'form-label']) }} {{ Form::text('address1',!empty($patient->address) ? $patient->address->address1 : null,['class' => 'form-control','placeholder' => __('messages.patient.address1')]) }}

{{ Form::label('address2',__('messages.patient.address2').':' ,['class' => 'form-label']) }} {{ Form::text('address2',!empty($patient->address) ? $patient->address->address2 : null,['class' => 'form-control','placeholder' => __('messages.patient.address2')]) }}

{{ Form::label('country_id',__('messages.country.country').':',['class'=>'form-label']) }} {{ Form::select('country_id', $data['countries'] ,null, ['id' => 'patientCountryId','data-placeholder' => __('messages.country.country'),'class' => 'form-select io-select2', 'aria-label'=>"Select a Country", 'data-control'=>'select2']) }}

{{ Form::label('state_id',__('messages.state.state').':',['class'=>'form-label']) }} {{ Form::select('state_id', [], null, ['id' => 'patientStateId','class' => 'form-select io-select2', 'data-placeholder' => __('messages.common.select_state'),'aria-label'=>"Select State",'data-control'=>'select2']) }}

{{ Form::label('city_id',__('messages.city.city').':',['class'=>'form-label']) }} {{ Form::select('city_id', [], null, ['id' => 'patientCityId','class' => 'form-select io-select2', 'data-placeholder' => __('messages.common.select_city'),'aria-label'=>"Select City",'data-control'=>'select2']) }}

{{ Form::label('postalCode',__('messages.patient.postal_code').':' ,['class' => 'form-label']) }} {{ Form::text('postal_code',!empty($patient->address) ? $patient->address->postal_code : null,['class' => 'form-control','placeholder' => __('messages.patient.postal_code')]) }}

{{ Form::submit(__('messages.common.save'),['class' => 'btn btn-primary me-2']) }} {{__('messages.common.discard')}}