{{-- Extends layout --}}
@extends(getThemeBasePath())

@section('page_title')
{{$page_title}}
@endsection

{{-- Content --}}
@section('content')
<!--begin::Card-->
<form class="form" method="post" action="{{$action}}" id="manage_form" enctype="multipart/form-data">
    @if(!empty($data['id']))
    @method('PUT')
    @endif
    @csrf
    <div class="card shadow-sm">
        <!--begin::Card header-->
        <div class="card-header card-header-tabs-line nav-tabs-line-3x">
            <!--begin::Toolbar-->
            <div class="card-toolbar">
                <ul class="nav nav-tabs nav-line-tabs nav-stretch fs-6 border-0">
                    <!--begin::Item-->
                    <li class="nav-item me-3">
                        <a class="nav-link active" data-bs-toggle="tab" href="#kt_user_edit_tab_1">
                            <span class="nav-icon">
                                <i class="fa fa-user"></i>
                            </span>
                            <span class="nav-text font-size-lg">{{$page_title}}</span>
                        </a>
                    </li>
                </ul>
            </div>
            <!--end::Toolbar-->
        </div>
        <!--end::Card header-->
        <!--begin::Card body-->
        <div class="card-body">

            <div class="tab-content">
                <div class="tab-pane show px-7" id="kt_user_edit_tab_2" role="tabpanel">
                    <!--begin::Row-->
                    <div class="row">
                        <div class="col-xl-10 my-2">

                        </div>
                    </div>
                </div>

                <!--begin::Tab-->
                <div class="tab-pane show active px-7" id="kt_user_edit_tab_1" role="tabpanel">
                    <!--begin::Row-->
                    <div class="row">
                        @include("backend.errors")
                        <div class="form-group row mb-5">
                            <div class="col-xl-6 col-lg-6 col-md-6 col-sm-12 col-xs-12 mb-3">
                                {!!Helper::getClientManageDropDown(['selectedClientId' => ($data['client_id'] ?? ''), 'isRequired' => true, 'extraClass' => 'client_select_dropdown','labelClass' => 'col-form-label col-12', 'inputDivClass' => 'col-xl-12 col-lg-12 col-md-12 col-sm-12 col-xs-12'])!!}
                            </div>
                            <!--begin::Group-->
                            <div class="col-xl-6 col-lg-6 col-md-6 col-sm-12 col-xs-12 mb-3">
                                <label class="col-form-label text-lg-right text-left">Upload File</label>
                                <input type="file" class="form-control" id="upload_file" name="upload_file" accept="image/*">
                            </div>
                            @if(isset($data['upload_file']) && !empty($data['upload_file']))
                            <div class="form-group fv-row mb-7">
                                <label class="col-form-label col-3 text-lg-right text-left"></label>
                                <div class="col-9">
                                    <a href="{{asset('/uploads/informationsharing/'.$data['upload_file'])}}" target="_blank"><img src="{{asset('/uploads/informationsharing/'.$data['upload_file'])}}" style="width: 100px;" /></a>
                                </div>
                            </div>
                            @endif
                            <!--end::Group-->
                        </div>

                        <div class="col-md-12">
                            <h3>Part A:Informatio about you (participant)</h3>
                            <hr>
                        </div>
                        <div class="form-group row mb-3">

                            <!--begin::Group-->
                            <div class="col-xl-4 col-lg-4 col-md-4 col-sm-12 col-xs-12 mb-3">
                                <label class="col-form-label text-lg-right text-left">Name</label>
                                <input class="form-control form-control-lg form-control-solid client_name" type="text" name="surname" value="{{$clientdata['name']??''}}" readonly />
                            </div>
                            <!--end::Group-->
                            <!--begin::Group-->
                            <div class="col-xl-4 col-lg-4 col-md-4 col-sm-12 col-xs-12 mb-3">
                                <label class="col-form-label text-lg-right text-left">Date of Birth</label>
                                <div class="input-group input-group-lg input-group-solid">
                                    <span class="input-group-text">
                                        <i class="la la-calendar"></i>
                                    </span>
                                    <input class="form-control form-control-lg form-control-solid datepicker client_dob" type="text" id="dob" value="{{$clientdata['dob']??''}}" autocomplete="off" readonly />
                                </div>
                            </div>
                            <!--end::Group-->

                            <!--begin::Group-->
                            <div class="col-xl-4 col-lg-4 col-md-4 col-sm-12 col-xs-12 mb-3">
                                <label class="col-form-label text-lg-right text-left">Contact Details (next of kin)</label>
                                @php
                                $referre_contact_details = [];
                                $referre_contact_details[] = trim($clientdata['referre_contact_details']??'');
                                $referre_contact_details[] = trim($clientdata['address']??'');
                                $referre_contact_details = implode(",",array_values(array_filter($referre_contact_details)));
                                @endphp
                                <textarea type="text" class="form-control form-control-lg form-control-solid client_mobile" placeholder="Phone" readonly>{{$referre_contact_details}}</textarea>
                            </div>
                            <!--end::Group-->
                        </div>
                        <div class="col-md-12">
                            <h3>Part B:Parent,Legal Gurdian or Representive</h3>
                            <hr>
                        </div>
                        <div class="form-group row mb-3">

                            <!--begin::Group-->
                            <div class="col-xl-4 col-lg-4 col-md-4 col-sm-12 col-xs-12 mb-3">
                                <label class="col-form-label text-lg-right text-left">Surname</label>
                                <input class="form-control form-control-lg form-control-solid " type="text" name="parent_surname" value="{{$data['parent_surname']??''}}" />
                            </div>
                            <!--end::Group-->

                            <!--begin::Group-->
                            <div class="col-xl-4 col-lg-4 col-md-4 col-sm-12 col-xs-12 mb-3">
                                <label class="col-form-label text-lg-right text-left">Given Name</label>
                                <input class="form-control form-control-lg form-control-solid " type="text" name="parent_givenname" value="{{$data['parent_givenname']??''}}" />
                            </div>
                            <!--end::Group-->

                            <!--begin::Group-->
                            <div class="col-xl-4 col-lg-4 col-md-4 col-sm-12 col-xs-12 mb-3">
                                <label class="col-form-label text-lg-right text-left">What is your relationship with the person requesting access ?</label>
                                <input class="form-control form-control-lg form-control-solid " type="text" name="relationship" value="{{$data['relationship']??''}}" />
                            </div>
                            <!--end::Group-->
                        </div>

                        <div class="col-md-12">
                            <h3>Contact Details</h3>
                            <hr>
                        </div>
                        <div class="form-group row mb-3">

                            <!--begin::Group-->
                            <div class="col-xl-4 col-lg-4 col-md-4 col-sm-12 col-xs-12 mb-3">
                                <label class="col-form-label text-lg-right text-left">Postal Address</label>
                                <input class="form-control form-control-lg form-control-solid " type="text" name="postal_address" value="{{$data['postal_address']??''}}" />
                            </div>
                            <!--end::Group-->

                            <!--begin::Group-->
                            <div class="col-xl-4 col-lg-4 col-md-4 col-sm-12 col-xs-12 mb-3">
                                <label class="col-form-label text-lg-right text-left">Phone Number</label>
                                <input class="form-control form-control-lg form-control-solid digits" type="text" name="phone_number" value="{{$data['phone_number']??''}}" />
                            </div>
                            <!--end::Group-->

                            <!--begin::Group-->
                            <div class="col-xl-4 col-lg-4 col-md-4 col-sm-12 col-xs-12 mb-3">
                                <label class="col-form-label text-lg-right text-left">Email</label>
                                <input class="form-control form-control-lg form-control-solid email" type="email" name="email" value="{{$data['email']??''}}" />
                            </div>
                            <!--end::Group-->

                        </div>
                        <div class="col-md-12">
                            <h3>Part C: Your information and privacy</h3>
                            <hr>
                            <p>Any personal information held by the {{$settings['app_name']??"We Care Cloud"}} is protected under the National Disability Insurance Scheme Act 2013 and the Privacy Act 1988.</p>

                        </div>
                        <div class="col-md-12">
                            <h3>Part D: Giving consent</h3>
                            <hr>
                            <p>Do you consent to the {{$settings['app_short_name']??"We Care Cloud"}} talking to other people about you; giving them information about you and getting information about you from:</p>

                        </div>
                        <div class="form-group row mb-3">

                            <!--begin::Group-->
                            <div class="col-xl-6 col-lg-6 col-md-6 col-sm-12 col-xs-12 mb-3">
                                <label class="col-form-label col-12">1. The Australian Government Department of Human Services (including Centrelink and Medicare)</label>
                                <div class="col-12">
                                    <div class="checkbox-list">
                                        <label class="checkbox">
                                            <input type="radio" class="form-check-input" name="aus_dept" value="Yes" {{isset($data['aus_dept']) && $data['aus_dept']=="Yes" ? 'checked' : ''}} />
                                            Yes</label>

                                        <!--begin::Group-->
                                        <div class="form-group fv-row mb-7">
                                            <label class="col-form-label text-lg-right text-left">I consent. My CRN is</label>
                                            <input class="form-control form-control-lg form-control-solid " type="text" name="crn" value="{{ $data['crn']??'' }}" />
                                        </div>
                                        <!--end::Group-->

                                        <label class="checkbox">
                                            <input type="radio" class="form-check-input" name="aus_dept" value="No" {{isset($data['aus_dept']) && $data['aus_dept']=="No" ? 'checked' : ''}} />
                                            No</label>
                                    </div>
                                </div>
                            </div>
                            <!--end::Group-->

                            <!--begin::Group-->
                            <div class="col-xl-6 col-lg-6 col-md-6 col-sm-12 col-xs-12 mb-3">
                                <label class="col-form-label col-12">2. State and Territory government departments</label>
                                <div class="col-12">
                                    <div class="checkbox-list">
                                        <label class="checkbox">
                                            <input type="radio" class="form-check-input" class="form-check-input" name="state" value="Yes" {{isset($data['state']) && $data['state'] == "Yes" ? 'checked':''}} />
                                            Yes, I consent or</label>
                                        <label class="checkbox">
                                            <input type="radio" class="form-check-input" class="form-check-input" name="state" value="No" {{isset($data['state']) && $data['state'] == "No" ? 'checked':''}} />
                                            No, I do not consent. I will provide the information myself.</label>
                                    </div>
                                </div>
                            </div>
                            <!--end::Group-->

                            <!--begin::Group-->
                            <div class="col-xl-6 col-lg-6 col-md-6 col-sm-12 col-xs-12 mb-3">
                                <label class="col-form-label col-12">3. Your medical practitioners and health professionals</label>
                                <div class="col-12">
                                    <div class="checkbox-list">
                                        <label class="checkbox">
                                            <input type="radio" class="form-check-input" name="medical" value="Yes" {{isset($data['medical']) && $data['medical'] == "Yes" ? 'checked':''}} />
                                            Yes, I consent or</label>
                                        <label class="checkbox">
                                            <input type="radio" class="form-check-input" name="medical" value="No" {{isset($data['medical']) && $data['medical'] == "No" ? 'checked':''}} />
                                            No, I do not consent. I will provide the information myself.</label>
                                    </div>
                                </div>
                            </div>
                            <!--end::Group-->

                            <!--begin::Group-->
                            <div class="col-xl-6 col-lg-6 col-md-6 col-sm-12 col-xs-12 mb-3">
                                <label class="col-form-label col-12">4.Your service providers</label>
                                <div class="col-12">
                                    <div class="checkbox-list">
                                        <label class="checkbox">
                                            <input type="radio" class="form-check-input" name="service_provider" value="Yes" {{isset($data['service_provider']) && $data['service_provider'] == "Yes" ? 'checked':''}} />
                                            Yes, I consent or</label>
                                        <label class="checkbox">
                                            <input type="radio" class="form-check-input" name="service_provider" value="No" {{isset($data['service_provider']) && $data['service_provider'] == "No" ? 'checked':''}} />
                                            No, I do not consent. I will provide the information myself.</label>
                                    </div>
                                </div>
                            </div>
                            <!--end::Group-->

                            <!--begin::Group-->
                            <div class="col-xl-6 col-lg-6 col-md-6 col-sm-12 col-xs-12 mb-3">
                                <label class="col-form-label col-12">5. Any schools you have attended</label>
                                <div class="col-12">
                                    <div class="checkbox-list">
                                        <label class="checkbox">
                                            <input type="radio" class="form-check-input" name="school_attend" value="Yes" {{isset($data['school_attend']) && $data['school_attend'] == "Yes" ? 'checked':''}} />
                                            Yes, I consent or</label>
                                        <label class="checkbox">
                                            <input type="radio" class="form-check-input" name="school_attend" value="No" {{isset($data['school_attend']) && $data['school_attend'] == "No" ? 'checked':''}} />
                                            No, I do not consent. I will provide the information myself.</label>
                                    </div>
                                </div>
                            </div>
                            <!--end::Group-->

                            <h4>
                                <p>Other Third Parties</p>
                            </h4>
                            <hr>
                            <p>If there are other people or organisations who have information about you the {{$settings['app_short_name']??"We Care Cloud"}} might need, please list them below, with an address and the details of a person to contact.</p>

                            <!--begin::Group-->
                            <div class="col-xl-6 col-lg-6 col-md-6 col-sm-12 col-xs-12 mb-3">
                                <label class="col-form-label text-lg-right text-left">Name of Third Party </label>
                                <input class="form-control form-control-lg form-control-solid" type="text" name="name_of_third_party" value="{{$data['name_of_third_party']??''}}" />
                            </div>
                            <!--end::Group-->

                            <!--begin::Group-->
                            <div class="col-xl-6 col-lg-6 col-md-6 col-sm-12 col-xs-12 mb-3">
                                <label class="col-form-label text-lg-right text-left">Details</label>
                                <input class="form-control form-control-lg form-control-solid" type="text" name="third_party_details" value="{{$data['third_party_details']??''}}" />
                            </div>
                            <!--end::Group-->

                            <!--begin::Group-->
                            <div class="form-group fv-row mb-7">
                                <div class="checkbox-list">
                                    <label class="checkbox">
                                        <input type="checkbox" class="form-check-input" name="agree1" value="Yes" {{isset($data['agree1']) && $data['agree1'] == "Yes" ? 'checked':''}} />&nbsp;&nbsp;&nbsp;
                                        Yes, I consent to the {{$settings['app_short_name']??"We Care Cloud"}} contacting the above parties and exchanging information about me with them</label>
                                </div>
                            </div>
                            <!--end::Group-->

                        </div>
                        <div class="col-md-12">
                            <h3>Part E: Signature</h3>
                            <hr>


                        </div>
                        <div class="col-xl-2"></div>
                        <div class="form-group row mb-3">
                            <!--begin::Group-->
                            <div class="col-xl-12 col-lg-12 col-md-12 col-sm-12 col-xs-12 mb-3">
                                <div class="checkbox-list">
                                    <label class="checkbox">
                                        <input type="checkbox" class="form-check-input" name="agree2" value="Yes" {{isset($data['agree2']) && $data['agree2'] == "Yes" ? 'checked':''}} />&nbsp;&nbsp;&nbsp;
                                        I understand I can obtain further information about how the {{$settings['app_short_name']??"We Care Cloud"}} handles my personal information from the Privacy Notice or Privacy Policy on the {{$settings['app_short_name']??"We Care Cloud"}} website.</label>
                                </div>
                            </div>
                            <!--end::Group-->

                            <!--begin::Group-->
                            <div class="col-xl-12 col-lg-12 col-md-12 col-sm-12 col-xs-12 mb-3">
                                <div class="checkbox-list">
                                    <label class="checkbox">
                                        <input type="checkbox" class="form-check-input" name="agree3" value="Yes" {{isset($data['agree3']) && $data['agree3'] == "Yes" ? 'checked':''}} />&nbsp;&nbsp;&nbsp;
                                        I understand I have given the {{$settings['app_short_name']??"We Care Cloud"}} consent to ask for information about me and share my information with third parties.</label>
                                </div>
                            </div>
                            <!--end::Group-->

                            <!--begin::Group-->
                            <div class="col-xl-4 col-lg-4 col-md-4 col-sm-12 col-xs-12 mb-3">
                                <label class="col-form-label text-lg-right text-left no-required">Name: </label>
                                <input class="form-control form-control-lg form-control-solid no-required" type="text" name="name" value="{{$data['name']??''}}" />
                            </div>
                            <!--end::Group-->

                            <!--begin::Group-->
                            <div class="col-xl-4 col-lg-4 col-md-4 col-sm-12 col-xs-12 mb-3">
                                <label class="col-form-label text-lg-right text-left no-required">Signature: </label>
                                <input class="form-control form-control-lg form-control-solid no-required" type="text" name="signature" value="{{$data['signature']??''}}" />
                            </div>
                            <!--end::Group-->

                            <!--begin::Group-->
                            <div class="col-xl-4 col-lg-4 col-md-4 col-sm-12 col-xs-12 mb-3">
                                <label class="col-form-label text-lg-right text-left no-required">Date</label>
                                <div class="input-group input-group-lg input-group-solid">
                                    <span class="input-group-text">
                                        <i class="la la-calendar"></i>
                                    </span>
                                    <input class="form-control form-control-lg form-control-solid datepicker no-required" type="text" name="date" id="dob" value="{{$data['date']??''}}" autocomplete="off" />
                                </div>
                            </div>
                            <!--end::Group-->

                            <!--begin::Group-->
                            <div class="form-group fv-row mb-7">
                                <div class="checkbox-list">
                                    <label class="checkbox">
                                        <input type="checkbox" class="form-check-input" name="agree4" value="Yes" {{isset($data['agree4']) && $data['agree4'] == "Yes" ? 'checked':''}} />&nbsp;&nbsp;&nbsp;
                                        I understand I can withdraw my consent at any time.</label>
                                </div>
                            </div>
                            <!--end::Group-->
                        </div>



                    </div>
                    <!--end::Row-->
                </div>
                <!--end::Tab-->
            </div>
        </div>
        <!--begin::Card body-->
        <div class="card-footer text-right">
            <button type="submit" id="submit_btn" class="btn btn-primary me-2 btn-hover-rise">Submit</button>
            <a href="{{route('informationsharing.index')}}"><button type="button" class="btn btn-secondary btn-hover-rise">Cancel</button></a>
        </div>
    </div>
    <!--end::Card-->
</form>
@endsection

{{-- Scripts Section --}}
@section('scripts')
<script type="text/javascript">
    $(document).ready(function() {
        $('#manage_form').validate({
            ignore: [],
            messages: {
                phone: "Please enter valid contact number",
                cpassword: "Please confirm same password again"
            }
        });
    });
</script>
@endsection