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Filename : 68c5c8f8cdb018bcada4ee0a92973b28.php
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<div class="alert alert-danger d-none" id="patientErrorBox"></div>
<div class="row gx-10 mb-5">
    <div class="col-md-6">
        <div class="form-group mb-5">
            <?php echo e(Form::label('first_name', __('messages.user.first_name').':', ['class' => 'form-label'])); ?>

            <span class="required"></span>
            <?php echo e(Form::text('first_name', null, ['class' => 'form-control', 'required', 'id' => 'patientFirstName','tabindex' => '1'])); ?>

        </div>
    </div>
    <div class="col-md-6">
        <div class="form-group mb-5">
            <?php echo e(Form::label('last_name', __('messages.user.last_name').':', ['class' => 'form-label'])); ?>

            <span class="required"></span>
            <?php echo e(Form::text('last_name', null, ['class' => 'form-control', 'required', 'tabindex' => '2'])); ?>

        </div>
    </div>
    <div class="col-md-6">
        <div class="form-group mb-5">
            <?php echo e(Form::label('email', __('messages.user.email').':', ['class' => 'form-label'])); ?>

            <span class="required"></span>
            <?php echo e(Form::text('email', null, ['class' => 'form-control','required'])); ?>

        </div>
    </div>
    <div class="col-md-6">
        <div class="form-group mb-5">
            <?php echo e(Form::label('dob', __('messages.user.dob').':', ['class' => 'form-label'])); ?>

            <?php echo e(Form::text('dob', null, ['class' => (getLoggedInUser()->thememode ? 'bg-light patientBirthDate form-control' : 'bg-white patientBirthDate form-control'), 'id' => 'patientBirthDate', 'autocomplete' => 'off', 'tabindex' => '4'])); ?>

        </div>
    </div>
    <div class="col-md-6">
        <div class="form-group mobile-overlapping  mb-5">
            <?php echo e(Form::label('phone', __('messages.user.phone').':', ['class' => 'form-label'])); ?>

            <span class="required"></span><br>
            <?php echo e(Form::tel('phone', getCountryCode(), ['class' => 'form-control phoneNumber', 'id' => 'patientPhoneNumber', 'required', 'onkeyup' => 'if (/\D/g.test(this.value)) this.value = this.value.replace(/\D/g,"")', 'tabindex' => '5'])); ?>

            <?php echo e(Form::hidden('prefix_code',null,['class'=>'prefix_code'])); ?>

            <span class="text-success valid-msg d-none fw-400 fs-small mt-2">✓ &nbsp; <?php echo e(__('messages.valid')); ?></span>
            <span class="text-danger error-msg d-none fw-400 fs-small mt-2"></span>
        </div>
    </div>
    <div class="col-md-3">
        <div class="form-group mb-5">
            <?php echo e(Form::label('gender', __('messages.user.gender').':', ['class' => 'form-label'])); ?>

            <span
                class="required"></span> &nbsp;<br>
            <span class="is-valid">
                <label class="form-label"><?php echo e(__('messages.user.male')); ?></label>&nbsp;&nbsp;
                <?php echo e(Form::radio('gender', '0', true, ['class' => 'form-check-input', 'tabindex' => '6','id'=>'patientMale'])); ?> &nbsp;
                <label class="form-label"><?php echo e(__('messages.user.female')); ?></label>
                <?php echo e(Form::radio('gender', '1', false, ['class' => 'form-check-input', 'tabindex' => '7','id'=>'patientFemale'])); ?>

            </span>
        </div>
    </div>
    <div class="col-md-3">
        <div class="form-group mb-5">
            <?php echo e(Form::label('status', __('messages.common.status').':', ['class' => 'form-label'])); ?>

            <div class="form-check form-switch form-check-custom">
                <input class="form-check-input w-35px h-20px is-active" name="status" type="checkbox" value="1"
                    tabindex="8" checked>
            </div>
        </div>
    </div>
    <div class="col-md-6">
        <div class="form-group mb-5">
            <?php echo e(Form::label('blood_group', __('messages.user.blood_group').':', ['class' => 'form-label'])); ?>

            <?php echo e(Form::select('blood_group', $bloodGroup, null, ['class' => 'form-select', 'id' => 'patientBloodGroup', 'placeholder' => __('messages.user.select_blood_group'), 'data-control' => 'select2', 'tabindex' => "9"])); ?>

        </div>
    </div>
    <div class="col-md-3">
        <div class="form-group mb-5">
            <?php echo e(Form::label('password', __('messages.user.password').':', ['class' => 'form-label'])); ?><span class="required"></span>
            <?php echo e(Form::password('password', ['class' => 'form-control','required','min' => '6','max' => '10', 'tabindex' => '10'])); ?>

        </div>
    </div>
    <div class="col-md-3">
        <div class="form-group mb-5">
            <?php echo e(Form::label('password_confirmation', __('messages.user.password_confirmation').':', ['class' => 'form-label'])); ?>

            <span class="required"></span>
            <?php echo e(Form::password('password_confirmation', ['class' => 'form-control','required','min' => '6','max' => '10', 'tabindex' => '11'])); ?>

        </div>
    </div>
    <div class="form-group col-md-4 mb-5">
        <div class="row2" io-image-input="true">
            <?php echo e(Form::label('image',__('messages.common.profile').(':'), ['class' => 'form-label'])); ?>

            <div class="d-block">
                <?php
                $style = 'style=';
                $background = 'background-image:';
                ?>

                <div class="image-picker">
                    <div class="image previewImage" id="patientPreviewImage"
                    <?php echo e($style); ?>"<?php echo e($background); ?> url(<?php echo e(asset('assets/img/avatar.png')); ?>">
                    <span class="picker-edit rounded-circle text-gray-500 fs-small" title="<?php echo e(__('messages.common.profile')); ?>">
                        <label>
                            <i class="fa-solid fa-pen" id="profileImageIcon"></i>
                            <input type="file" id="patientProfileImage" name="image"
                                   class="image-upload d-none profileImage patientProfileImage" accept=".png, .jpg, .jpeg, .gif"/>
                            <input type="hidden" name="avatar_remove"/>
                        </label>
                    </span>
                </div>
            </div>
        </div>
    </div>
</div>
<hr>
<div class="row mt-3 mb-5">
    <div class="col-md-12 mb-3">
        <h5><?php echo e(__('messages.user.address_details')); ?></h5>
    </div>
    <div class="col-md-6">
        <div class="form-group mb-5">
            <?php echo e(Form::label('address1', __('messages.user.address1').':', ['class' => 'form-label'])); ?>

            <?php echo e(Form::text('address1', null, ['class' => 'form-control'])); ?>

        </div>
    </div>
    <div class="col-md-6">
        <div class="form-group mb-5">
            <?php echo e(Form::label('address2', __('messages.user.address2').':', ['class' => 'form-label'])); ?>

            <?php echo e(Form::text('address2', null, ['class' => 'form-control'])); ?>

        </div>
    </div>
    <div class="col-md-3">
        <div class="form-group mb-5">
            <?php echo e(Form::label('city', __('messages.user.city').':', ['class' => 'form-label'])); ?>

            <?php echo e(Form::text('city', null, ['class' => 'form-control'])); ?>

        </div>
    </div>
    <div class="col-md-3">
        <div class="form-group mb-5">
            <?php echo e(Form::label('zip', __('messages.user.zip').':', ['class' => 'form-label'])); ?>

            <?php echo e(Form::text('zip', null, ['class' => 'form-control', 'maxlength' => '6','minlength' => '6'])); ?>

        </div>
    </div>
</div>
<hr>
<div class="row mt-3 mb-5">
    <div class="col-md-12 mb-3">
        <h5><?php echo e(__('messages.setting.social_details')); ?></h5>
    </div>

    <!-- Facebook URL Field -->
    <div class="form-group col-sm-6 mb-5">
        <?php echo e(Form::label('facebook_url', __('messages.facebook_url').':', ['class' => 'form-label'])); ?>

        <?php echo e(Form::text('facebook_url', null, ['class' => 'form-control patientFacebookUrl','id'=>'patientFacebookUrl', 'onkeypress' => 'return avoidSpace(event);'])); ?>

    </div>

    <!-- Twitter URL Field -->
    <div class="form-group col-sm-6 mb-5">
        <?php echo e(Form::label('twitter_url', __('messages.twitter_url').':', ['class' => 'form-label'])); ?>

        <?php echo e(Form::text('twitter_url', null, ['class' => 'form-control patientTwitterUrl','id'=>'patientTwitterUrl', 'onkeypress' => 'return avoidSpace(event);'])); ?>

    </div>

    <!-- Instagram URL Field -->
    <div class="form-group col-sm-6 mb-5">
        <?php echo e(Form::label('instagram_url', __('messages.instagram_url').':', ['class' => 'form-label'])); ?>

        <?php echo e(Form::text('instagram_url', null, ['class' => 'form-control patientInstagramUrl', 'id'=>'patientInstagramUrl', 'onkeypress' => 'return avoidSpace(event);'])); ?>

    </div>

    <!-- LinkedIn URL Field -->
    <div class="form-group col-sm-6 mb-5">
        <?php echo e(Form::label('linkedIn_url', __('messages.linkedIn_url').':', ['class' => 'form-label'])); ?>

        <?php echo e(Form::text('linkedIn_url', null, ['class' => 'form-control patientLinkedInUrl','id'=>'patientLinkedInUrl', 'onkeypress' => 'return avoidSpace(event);'])); ?>

    </div>

</div>
<div class="d-flex justify-content-end">
    <?php echo e(Form::submit(__('messages.common.save'), ['class' => 'btn btn-primary me-2','id' => 'patientSave'])); ?>

    <a href="<?php echo e(route('patients.index')); ?>"
       class="btn btn-secondary me-2"><?php echo __('messages.common.cancel'); ?></a>
</div>
<?php /**PATH /home/u827283894/domains/w-manage.org/public_html/hms/resources/views/patients/fields.blade.php ENDPATH**/ ?>