@extends('admin.layouts.app')

@section('content')

<div class="col-12 grid-margin stretch-card">
    <div class="card">
        <div class="card-body">
            <h4 class="card-title">Add Patient</h4>
            <p class="card-description">
            </p>
            <form id="add_patient" class="forms-sample" method="post" action="{{ route('admin.patient.store') }}">
                @csrf
                <div class="row">
                    <div class="col-md-6">
                        <div class="form-group">
                            <label for="first_name" class="form-label required">First Name </label>
                            <input type="text" class="form-control @error('first_name') is-invalid @enderror" name="first_name" value="{{ old('first_name') }}">
                            @error('first_name')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                        <div class="form-group">
                            <label for="last_name" class="form-label required">Last Name</label>
                            <input type="text" class="form-control @error('last_name') is-invalid @enderror" name="last_name" value="{{ old('last_name') }}">
                            @error('last_name')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>



                        <div class="form-group">
                            <label for="middle_name" class="form-label required">Middle Name</label>
                            <input type="text" class="form-control @error('middle_name') is-invalid @enderror" name="middle_name" value="{{ old('middle_name') }}">
                            @error('middle_name')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                        <div class="form-group">
                            <label for="date_of_birth" class="form-label required">Date of Birth</label>
                            <input type="date" class="form-control @error('date_of_birth') is-invalid @enderror" name="date_of_birth" value="{{ old('date_of_birth') }}">
                            @error('date_of_birth')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>


                        <div class="form-group">
                            <label for="sex" class="form-label required">Gender</label>
                            <select class="form-select @error('sex') is-invalid @enderror" name="sex">
                                <option value="">Select Gender</option>
                                <option value="Male" {{ old('sex') == 'Male' ? 'selected' : '' }}>Male</option>
                                <option value="Female" {{ old('sex') == 'Female' ? 'selected' : '' }}>Female</option>
                                <option value="Other" {{ old('sex') == 'Other' ? 'selected' : '' }}>Other</option>
                            </select>
                            @error('sex')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>

                        <div class="form-group">
                            <label for="address" class="form-label required">Address</label>
                            <input type="text" class="form-control @error('address') is-invalid @enderror" name="address" value="{{ old('address') }}">
                            @error('address')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>

  

                        <div class="form-group">
                            <label for="patient_phone_num_country_code" class="form-label required">Phone Number (Country Code)</label>
                             <select name="patient_phone_num_country_code" id="country_code" class="form-select">
                                     <option value="+91">India (+91)</option>
                                    <option value="+93">Afghanistan (+93)</option>
                                    <option value="+355">Albania (+355)</option>
                                    <option value="+213">Algeria (+213)</option>
                                    <option value="+376">Andorra (+376)</option>
                                    <option value="+244">Angola (+244)</option>
                                    <option value="+1-268">Antigua and Barbuda (+1-268)</option>
                                    <option value="+54">Argentina (+54)</option>
                                    <option value="+374">Armenia (+374)</option>
                                    <option value="+61">Australia (+61)</option>
                                    <option value="+43">Austria (+43)</option>
                                    <option value="+994">Azerbaijan (+994)</option>
                                    <option value="+1-242">Bahamas (+1-242)</option>
                                    <option value="+973">Bahrain (+973)</option>
                                    <option value="+880">Bangladesh (+880)</option>
                                    <option value="+1-246">Barbados (+1-246)</option>
                                    <option value="+375">Belarus (+375)</option>
                                    <option value="+32">Belgium (+32)</option>
                                    <option value="+226">Burkina Faso (+226)</option>
                                    <option value="+257">Burundi (+257)</option>
                                    <option value="+855">Cambodia (+855)</option>
                                    <option value="+237">Cameroon (+237)</option>
                                    <option value="+1-242">Canada (+1-242)</option>
                                    <option value="+238">Cape Verde (+238)</option>
                                    <option value="+1-345">Cayman Islands (+1-345)</option>
                                    <option value="+236">Central African Republic (+236)</option>
                                    <option value="+56">Chile (+56)</option>
                                    <option value="+86">China (+86)</option>
                                    <option value="+57">Colombia (+57)</option>
                                    <option value="+269">Comoros (+269)</option>
                                    <option value="+242">Congo (+242)</option>
                                    <option value="+243">Congo (DRC) (+243)</option>
                                    <option value="+682">Cook Islands (+682)</option>
                                    <option value="+506">Costa Rica (+506)</option>
                                    <option value="+225">Cote d Ivoire (+225)</option>
                                    <option value="+385">Croatia (+385)</option>
                                    <option value="+53">Cuba (+53)</option>
                                    <option value="+357">Cyprus (+357)</option>
                                    <option value="+420">Czech Republic (+420)</option>
                                    <option value="+45">Denmark (+45)</option>
                                    <option value="+253">Djibouti (+253)</option>
                                    <option value="+1-767">Dominica (+1-767)</option>
                                    <option value="+1-809">Dominican Republic (+1-809)</option>
                                    <option value="+593">Ecuador (+593)</option>
                                    <option value="+20">Egypt (+20)</option>
                                    <option value="+503">El Salvador (+503)</option>
                                    <option value="+240">Equatorial Guinea (+240)</option>
                                    <option value="+291">Eritrea (+291)</option>
                                    <option value="+372">Estonia (+372)</option>
                                    <option value="+251">Ethiopia (+251)</option>
                                    <option value="+679">Fiji (+679)</option>
                                    <option value="+358">Finland (+358)</option>
                                    <option value="+33">France (+33)</option>
                                    <option value="+594">French Guiana (+594)</option>
                                    <option value="+689">French Polynesia (+689)</option>
                                    <option value="+241">Gabon (+241)</option>
                                    <option value="+220">Gambia (+220)</option>
                                    <option value="+995">Georgia (+995)</option>
                                    <option value="+49">Germany (+49)</option>
                                    <option value="+233">Ghana (+233)</option>
                                    <option value="+30">Greece (+30)</option>
                                    <option value="+1-473">Grenada (+1-473)</option>
                                    <option value="+502">Guatemala (+502)</option>
                                    <option value="+224">Guinea (+224)</option>
                                    <option value="+245">Guinea-Bissau (+245)</option>
                                    <option value="+592">Guyana (+592)</option>
                                    <option value="+509">Haiti (+509)</option>
                                    <option value="+504">Honduras (+504)</option>
                                    <option value="+852">Hong Kong (+852)</option>
                                    <option value="+36">Hungary (+36)</option>
                                    <option value="+354">Iceland (+354)</option>
                                    <option value="+62">Indonesia (+62)</option>
                                    <option value="+98">Iran (+98)</option>
                                    <option value="+964">Iraq (+964)</option>
                                    <option value="+353">Ireland (+353)</option>
                                    <option value="+972">Israel (+972)</option>
                                    <option value="+39">Italy (+39)</option>
                                    <option value="+1-876">Jamaica (+1-876)</option>
                                    <option value="+81">Japan (+81)</option>
                                    <option value="+962">Jordan (+962)</option>
                                    <option value="+7">Kazakhstan (+7)</option>
                                    <option value="+254">Kenya (+254)</option>
                                    <option value="+686">Kiribati (+686)</option>
                                    <option value="+965">Kuwait (+965)</option>
                                    <option value="+996">Kyrgyzstan (+996)</option>
                                    <option value="+856">Laos (+856)</option>
                                    <option value="+371">Latvia (+371)</option>
                                    <option value="+961">Lebanon (+961)</option>
                                    <option value="+266">Lesotho (+266)</option>
                                    <option value="+231">Liberia (+231)</option>
                                    <option value="+218">Libya (+218)</option>
                                    <option value="+423">Liechtenstein (+423)</option>
                                    <option value="+370">Lithuania (+370)</option>
                                    <option value="+352">Luxembourg (+352)</option>
                                    <option value="+853">Macau (+853)</option>
                                    <option value="+389">North Macedonia (+389)</option>
                                    <option value="+261">Madagascar (+261)</option>
                                    <option value="+265">Malawi (+265)</option>
                                    <option value="+60">Malaysia (+60)</option>
                                    <option value="+960">Maldives (+960)</option>
                                    <option value="+223">Mali (+223)</option>
                                    <option value="+356">Malta (+356)</option>
                                    <option value="+692">Marshall Islands (+692)</option>
                                    <option value="+596">Martinique (+596)</option>
                                    <option value="+222">Mauritania (+222)</option>
                                    <option value="+230">Mauritius (+230)</option>
                                    <option value="+52">Mexico (+52)</option>
                                    <option value="+373">Moldova (+373)</option>
                                    <option value="+377">Monaco (+377)</option>
                                    <option value="+976">Mongolia (+976)</option>
                                    <option value="+382">Montenegro (+382)</option>
                                    <option value="+1-664">Montserrat (+1-664)</option>
                                    <option value="+212">Morocco (+212)</option>
                                    <option value="+258">Mozambique (+258)</option>
                                    <option value="+95">Myanmar (+95)</option>
                                    <option value="+264">Namibia (+264)</option>
                                    <option value="+674">Nauru (+674)</option>
                                    <option value="+977">Nepal (+977)</option>
                                    <option value="+31">Netherlands (+31)</option>
                                    <option value="+599">Netherlands Antilles (+599)</option>
                                    <option value="+64">New Zealand (+64)</option>
                                    <option value="+505">Nicaragua (+505)</option>
                                    <option value="+227">Niger (+227)</option>
                                    <option value="+234">Nigeria (+234)</option>
                                    <option value="+683">Niue (+683)</option>
                                    <option value="+850">North Korea (+850)</option>
                                    <option value="+47">Norway (+47)</option>
                                    <option value="+968">Oman (+968)</option>
                                    <option value="+92">Pakistan (+92)</option>
                                    <option value="+680">Palau (+680)</option>
                                    <option value="+970">Palestinian Territories (+970)</option>
                                    <option value="+507">Panama (+507)</option>
                                    <option value="+675">Papua New Guinea (+675)</option>
                                    <option value="+595">Paraguay (+595)</option>
                                    <option value="+51">Peru (+51)</option>
                                    <option value="+63">Philippines (+63)</option>
                                    <option value="+48">Poland (+48)</option>
                                    <option value="+351">Portugal (+351)</option>
                                    <option value="+1-787">Puerto Rico (+1-787)</option>
                                    <option value="+974">Qatar (+974)</option>
                                    <option value="+40">Romania (+40)</option>
                                    <option value="+7">Russia (+7)</option>
                                    <option value="+250">Rwanda (+250)</option>
                                    <option value="+590">Saint Barthelemy (+590)</option>
                                    <option value="+290">Saint Helena (+290)</option>
                                    <option value="+1-869">Saint Kitts and Nevis (+1-869)</option>
                                    <option value="+1-758">Saint Lucia (+1-758)</option>
                                    <option value="+1-784">Saint Vincent and the Grenadines (+1-784)</option>
                                    <option value="+685">Samoa (+685)</option>
                                    <option value="+378">San Marino (+378)</option>
                                    <option value="+239">Sao Tome and Principe (+239)</option>
                                    <option value="+966">Saudi Arabia (+966)</option>
                                    <option value="+221">Senegal (+221)</option>
                                    <option value="+381">Serbia (+381)</option>
                                    <option value="+248">Seychelles (+248)</option>
                                    <option value="+232">Sierra Leone (+232)</option>
                                    <option value="+65">Singapore (+65)</option>
                                    <option value="+421">Slovakia (+421)</option>
                                    <option value="+386">Slovenia (+386)</option>
                                    <option value="+677">Solomon Islands (+677)</option>
                                    <option value="+252">Somalia (+252)</option>
                                    <option value="+27">South Africa (+27)</option>
                                    <option value="+82">South Korea (+82)</option>
                                    <option value="+211">South Sudan (+211)</option>
                                    <option value="+34">Spain (+34)</option>
                                    <option value="+94">Sri Lanka (+94)</option>
                                    <option value="+249">Sudan (+249)</option>
                                    <option value="+597">Suriname (+597)</option>
                                    <option value="+47">Svalbard and Jan Mayen (+47)</option>
                                    <option value="+268">Swaziland (+268)</option>
                                    <option value="+46">Sweden (+46)</option>
                                    <option value="+41">Switzerland (+41)</option>
                                    <option value="+963">Syria (+963)</option>
                                    <option value="+886">Taiwan (+886)</option>
                                    <option value="+255">Tanzania (+255)</option>
                                    <option value="+66">Thailand (+66)</option>
                                    <option value="+670">Timor-Leste (+670)</option>
                                    <option value="+228">Togo (+228)</option>
                                    <option value="+690">Tokelau (+690)</option>
                                    <option value="+676">Tonga (+676)</option>
                                    <option value="+1-868">Trinidad and Tobago (+1-868)</option>
                                    <option value="+216">Tunisia (+216)</option>
                                    <option value="+90">Turkey (+90)</option>
                                    <option value="+993">Turkmenistan (+993)</option>
                                    <option value="+1-649">Turks and Caicos Islands (+1-649)</option>
                                    <option value="+688">Tuvalu (+688)</option>
                                    <option value="+256">Uganda (+256)</option>
                                    <option value="+380">Ukraine (+380)</option>
                                    <option value="+971">United Arab Emirates (+971)</option>
                                    <option value="+44">United Kingdom (+44)</option>
                                    <option value="+1">United States (+1)</option>
                                    <option value="+598">Uruguay (+598)</option>
                                    <option value="+998">Uzbekistan (+998)</option>
                                    <option value="+678">Vanuatu (+678)</option>
                                    <option value="+58">Venezuela (+58)</option>
                                    <option value="+84">Vietnam (+84)</option>
                                    <option value="+1-340">Virgin Islands (+1-340)</option>
                                    <option value="+967">Yemen (+967)</option>
                                    <option value="+260">Zambia (+260)</option>
                                    <option value="+263">Zimbabwe (+263)</option>
                                </select>
                            
                               @error('patient_phone_num_country_code')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                        <div class="form-group">
                            <label for="patient_phone_number" class="form-label required">Phone Number</label>

                            <input type="text" class="form-control @error('patient_phone_number') is-invalid @enderror" name="patient_phone_number" value="{{ old('patient_phone_number')  }}">
                            @error('patient_phone_number')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>



                        <div class="form-group">
                            <label for="patient_er_country_code" class="form-label required">Emergency Phone Number (Country Code)</label>
                            <select name="patient_er_country_code" id="country_code" class="form-select">
                                    <option value="+91">India (+91)</option>
                                    <option value="+93">Afghanistan (+93)</option>
                                    <option value="+355">Albania (+355)</option>
                                    <option value="+213">Algeria (+213)</option>
                                    <option value="+376">Andorra (+376)</option>
                                    <option value="+244">Angola (+244)</option>
                                    <option value="+1-268">Antigua and Barbuda (+1-268)</option>
                                    <option value="+54">Argentina (+54)</option>
                                    <option value="+374">Armenia (+374)</option>
                                    <option value="+61">Australia (+61)</option>
                                    <option value="+43">Austria (+43)</option>
                                    <option value="+994">Azerbaijan (+994)</option>
                                    <option value="+1-242">Bahamas (+1-242)</option>
                                    <option value="+973">Bahrain (+973)</option>
                                    <option value="+880">Bangladesh (+880)</option>
                                    <option value="+1-246">Barbados (+1-246)</option>
                                    <option value="+375">Belarus (+375)</option>
                                    <option value="+32">Belgium (+32)</option>
                                    <option value="+226">Burkina Faso (+226)</option>
                                    <option value="+257">Burundi (+257)</option>
                                    <option value="+855">Cambodia (+855)</option>
                                    <option value="+237">Cameroon (+237)</option>
                                    <option value="+1-242">Canada (+1-242)</option>
                                    <option value="+238">Cape Verde (+238)</option>
                                    <option value="+1-345">Cayman Islands (+1-345)</option>
                                    <option value="+236">Central African Republic (+236)</option>
                                    <option value="+56">Chile (+56)</option>
                                    <option value="+86">China (+86)</option>
                                    <option value="+57">Colombia (+57)</option>
                                    <option value="+269">Comoros (+269)</option>
                                    <option value="+242">Congo (+242)</option>
                                    <option value="+243">Congo (DRC) (+243)</option>
                                    <option value="+682">Cook Islands (+682)</option>
                                    <option value="+506">Costa Rica (+506)</option>
                                    <option value="+225">Cote d Ivoire (+225)</option>
                                    <option value="+385">Croatia (+385)</option>
                                    <option value="+53">Cuba (+53)</option>
                                    <option value="+357">Cyprus (+357)</option>
                                    <option value="+420">Czech Republic (+420)</option>
                                    <option value="+45">Denmark (+45)</option>
                                    <option value="+253">Djibouti (+253)</option>
                                    <option value="+1-767">Dominica (+1-767)</option>
                                    <option value="+1-809">Dominican Republic (+1-809)</option>
                                    <option value="+593">Ecuador (+593)</option>
                                    <option value="+20">Egypt (+20)</option>
                                    <option value="+503">El Salvador (+503)</option>
                                    <option value="+240">Equatorial Guinea (+240)</option>
                                    <option value="+291">Eritrea (+291)</option>
                                    <option value="+372">Estonia (+372)</option>
                                    <option value="+251">Ethiopia (+251)</option>
                                    <option value="+679">Fiji (+679)</option>
                                    <option value="+358">Finland (+358)</option>
                                    <option value="+33">France (+33)</option>
                                    <option value="+594">French Guiana (+594)</option>
                                    <option value="+689">French Polynesia (+689)</option>
                                    <option value="+241">Gabon (+241)</option>
                                    <option value="+220">Gambia (+220)</option>
                                    <option value="+995">Georgia (+995)</option>
                                    <option value="+49">Germany (+49)</option>
                                    <option value="+233">Ghana (+233)</option>
                                    <option value="+30">Greece (+30)</option>
                                    <option value="+1-473">Grenada (+1-473)</option>
                                    <option value="+502">Guatemala (+502)</option>
                                    <option value="+224">Guinea (+224)</option>
                                    <option value="+245">Guinea-Bissau (+245)</option>
                                    <option value="+592">Guyana (+592)</option>
                                    <option value="+509">Haiti (+509)</option>
                                    <option value="+504">Honduras (+504)</option>
                                    <option value="+852">Hong Kong (+852)</option>
                                    <option value="+36">Hungary (+36)</option>
                                    <option value="+354">Iceland (+354)</option>
                                    <option value="+62">Indonesia (+62)</option>
                                    <option value="+98">Iran (+98)</option>
                                    <option value="+964">Iraq (+964)</option>
                                    <option value="+353">Ireland (+353)</option>
                                    <option value="+972">Israel (+972)</option>
                                    <option value="+39">Italy (+39)</option>
                                    <option value="+1-876">Jamaica (+1-876)</option>
                                    <option value="+81">Japan (+81)</option>
                                    <option value="+962">Jordan (+962)</option>
                                    <option value="+7">Kazakhstan (+7)</option>
                                    <option value="+254">Kenya (+254)</option>
                                    <option value="+686">Kiribati (+686)</option>
                                    <option value="+965">Kuwait (+965)</option>
                                    <option value="+996">Kyrgyzstan (+996)</option>
                                    <option value="+856">Laos (+856)</option>
                                    <option value="+371">Latvia (+371)</option>
                                    <option value="+961">Lebanon (+961)</option>
                                    <option value="+266">Lesotho (+266)</option>
                                    <option value="+231">Liberia (+231)</option>
                                    <option value="+218">Libya (+218)</option>
                                    <option value="+423">Liechtenstein (+423)</option>
                                    <option value="+370">Lithuania (+370)</option>
                                    <option value="+352">Luxembourg (+352)</option>
                                    <option value="+853">Macau (+853)</option>
                                    <option value="+389">North Macedonia (+389)</option>
                                    <option value="+261">Madagascar (+261)</option>
                                    <option value="+265">Malawi (+265)</option>
                                    <option value="+60">Malaysia (+60)</option>
                                    <option value="+960">Maldives (+960)</option>
                                    <option value="+223">Mali (+223)</option>
                                    <option value="+356">Malta (+356)</option>
                                    <option value="+692">Marshall Islands (+692)</option>
                                    <option value="+596">Martinique (+596)</option>
                                    <option value="+222">Mauritania (+222)</option>
                                    <option value="+230">Mauritius (+230)</option>
                                    <option value="+52">Mexico (+52)</option>
                                    <option value="+373">Moldova (+373)</option>
                                    <option value="+377">Monaco (+377)</option>
                                    <option value="+976">Mongolia (+976)</option>
                                    <option value="+382">Montenegro (+382)</option>
                                    <option value="+1-664">Montserrat (+1-664)</option>
                                    <option value="+212">Morocco (+212)</option>
                                    <option value="+258">Mozambique (+258)</option>
                                    <option value="+95">Myanmar (+95)</option>
                                    <option value="+264">Namibia (+264)</option>
                                    <option value="+674">Nauru (+674)</option>
                                    <option value="+977">Nepal (+977)</option>
                                    <option value="+31">Netherlands (+31)</option>
                                    <option value="+599">Netherlands Antilles (+599)</option>
                                    <option value="+64">New Zealand (+64)</option>
                                    <option value="+505">Nicaragua (+505)</option>
                                    <option value="+227">Niger (+227)</option>
                                    <option value="+234">Nigeria (+234)</option>
                                    <option value="+683">Niue (+683)</option>
                                    <option value="+850">North Korea (+850)</option>
                                    <option value="+47">Norway (+47)</option>
                                    <option value="+968">Oman (+968)</option>
                                    <option value="+92">Pakistan (+92)</option>
                                    <option value="+680">Palau (+680)</option>
                                    <option value="+970">Palestinian Territories (+970)</option>
                                    <option value="+507">Panama (+507)</option>
                                    <option value="+675">Papua New Guinea (+675)</option>
                                    <option value="+595">Paraguay (+595)</option>
                                    <option value="+51">Peru (+51)</option>
                                    <option value="+63">Philippines (+63)</option>
                                    <option value="+48">Poland (+48)</option>
                                    <option value="+351">Portugal (+351)</option>
                                    <option value="+1-787">Puerto Rico (+1-787)</option>
                                    <option value="+974">Qatar (+974)</option>
                                    <option value="+40">Romania (+40)</option>
                                    <option value="+7">Russia (+7)</option>
                                    <option value="+250">Rwanda (+250)</option>
                                    <option value="+590">Saint Barthelemy (+590)</option>
                                    <option value="+290">Saint Helena (+290)</option>
                                    <option value="+1-869">Saint Kitts and Nevis (+1-869)</option>
                                    <option value="+1-758">Saint Lucia (+1-758)</option>
                                    <option value="+1-784">Saint Vincent and the Grenadines (+1-784)</option>
                                    <option value="+685">Samoa (+685)</option>
                                    <option value="+378">San Marino (+378)</option>
                                    <option value="+239">Sao Tome and Principe (+239)</option>
                                    <option value="+966">Saudi Arabia (+966)</option>
                                    <option value="+221">Senegal (+221)</option>
                                    <option value="+381">Serbia (+381)</option>
                                    <option value="+248">Seychelles (+248)</option>
                                    <option value="+232">Sierra Leone (+232)</option>
                                    <option value="+65">Singapore (+65)</option>
                                    <option value="+421">Slovakia (+421)</option>
                                    <option value="+386">Slovenia (+386)</option>
                                    <option value="+677">Solomon Islands (+677)</option>
                                    <option value="+252">Somalia (+252)</option>
                                    <option value="+27">South Africa (+27)</option>
                                    <option value="+82">South Korea (+82)</option>
                                    <option value="+211">South Sudan (+211)</option>
                                    <option value="+34">Spain (+34)</option>
                                    <option value="+94">Sri Lanka (+94)</option>
                                    <option value="+249">Sudan (+249)</option>
                                    <option value="+597">Suriname (+597)</option>
                                    <option value="+47">Svalbard and Jan Mayen (+47)</option>
                                    <option value="+268">Swaziland (+268)</option>
                                    <option value="+46">Sweden (+46)</option>
                                    <option value="+41">Switzerland (+41)</option>
                                    <option value="+963">Syria (+963)</option>
                                    <option value="+886">Taiwan (+886)</option>
                                    <option value="+255">Tanzania (+255)</option>
                                    <option value="+66">Thailand (+66)</option>
                                    <option value="+670">Timor-Leste (+670)</option>
                                    <option value="+228">Togo (+228)</option>
                                    <option value="+690">Tokelau (+690)</option>
                                    <option value="+676">Tonga (+676)</option>
                                    <option value="+1-868">Trinidad and Tobago (+1-868)</option>
                                    <option value="+216">Tunisia (+216)</option>
                                    <option value="+90">Turkey (+90)</option>
                                    <option value="+993">Turkmenistan (+993)</option>
                                    <option value="+1-649">Turks and Caicos Islands (+1-649)</option>
                                    <option value="+688">Tuvalu (+688)</option>
                                    <option value="+256">Uganda (+256)</option>
                                    <option value="+380">Ukraine (+380)</option>
                                    <option value="+971">United Arab Emirates (+971)</option>
                                    <option value="+44">United Kingdom (+44)</option>
                                    <option value="+1">United States (+1)</option>
                                    <option value="+598">Uruguay (+598)</option>
                                    <option value="+998">Uzbekistan (+998)</option>
                                    <option value="+678">Vanuatu (+678)</option>
                                    <option value="+58">Venezuela (+58)</option>
                                    <option value="+84">Vietnam (+84)</option>
                                    <option value="+1-340">Virgin Islands (+1-340)</option>
                                    <option value="+967">Yemen (+967)</option>
                                    <option value="+260">Zambia (+260)</option>
                                    <option value="+263">Zimbabwe (+263)</option>
                                </select>
                            @error('patient_er_country_code')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                        <div class="form-group">
                            <label for="patient_er_phone_number" class="form-label required">Emergency Phone Number</label>
                            <input type="text" class="form-control @error('patient_er_phone_number') is-invalid @enderror" name="patient_er_phone_number" value="{{ old('patient_er_phone_number') }}">
                            @error('patient_er_phone_number')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>



                        <div class="form-group">
                            <label for="aadhar_card_num" class="form-label required">Aadhar Card Number Last 4 Digits.</label>
                            <input type="text" class="form-control @error('aadhar_card_num') is-invalid @enderror" name="aadhar_card_num" maxlength="4" value="{{ old('aadhar_card_num') }}">
                            @error('aadhar_card_num')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                        
                        <div class="form-group">
                        <label for="blood_group" class="form-label">Blood Group (Optional)</label>
                                <div class="row">
                                    <div class="col-md-3">
                                        <div class="form-check">
                                            <input type="radio" class="form-check-input" id="blood_group_a_positive" name="blood_group" value="A+">
                                            <label class="form-check-label" for="blood_group_a_positive">A+</label>
                                        </div>
                                    </div>
                                    <div class="col-md-3">
                                        <div class="form-check">
                                            <input type="radio" class="form-check-input" id="blood_group_a_negative" name="blood_group" value="A-">
                                            <label class="form-check-label" for="blood_group_a_negative">A-</label>
                                        </div>
                                    </div>
                                    <div class="col-md-3">
                                        <div class="form-check">
                                            <input type="radio" class="form-check-input" id="blood_group_b_positive" name="blood_group" value="B+">
                                            <label class="form-check-label" for="blood_group_b_positive">B+</label>
                                        </div>
                                    </div>
                                    <div class="col-md-3">
                                        <div class="form-check">
                                            <input type="radio" class="form-check-input" id="blood_group_b_negative" name="blood_group" value="B-">
                                            <label class="form-check-label" for="blood_group_b_negative">B-</label>
                                        </div>
                                    </div>
                                    <div class="col-md-3">
                                        <div class="form-check">
                                            <input type="radio" class="form-check-input" id="blood_group_ab_positive" name="blood_group" value="AB+">
                                            <label class="form-check-label" for="blood_group_ab_positive">AB+</label>
                                        </div>
                                    </div>
                                    <div class="col-md-3">
                                        <div class="form-check">
                                            <input type="radio" class="form-check-input" id="blood_group_ab_negative" name="blood_group" value="AB-">
                                            <label class="form-check-label" for="blood_group_ab_negative">AB-</label>
                                        </div>
                                    </div>
                                    <div class="col-md-3">
                                        <div class="form-check">
                                            <input type="radio" class="form-check-input" id="blood_group_o_positive" name="blood_group" value="O+">
                                            <label class="form-check-label" for="blood_group_o_positive">O+</label>
                                        </div>
                                    </div>
                                    <div class="col-md-3">
                                        <div class="form-check">
                                            <input type="radio" class="form-check-input" id="blood_group_o_negative" name="blood_group" value="O-">
                                            <label class="form-check-label" for="blood_group_o_negative">O-</label>
                                        </div>
                                    </div>
                                </div>
                                @error('blood_group')
                                <span class="text-danger">{{ $message }}</span>
                                @enderror
                                </div>
                        <div class="form-group">
                            <label for="pan_card_num" class="form-label required">PAN Card Number</label>
                            <input type="text" class="form-control @error('pan_card_num') is-invalid @enderror" name="pan_card_num" maxlength="20" value="{{ old('pan_card_num') }}">
                            @error('pan_card_num')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>



                        <div class="form-group">
                            <label for="ssn_card_num" class="form-label required">SSN Card Number</label>
                            <input type="text" class="form-control @error('ssn_card_num') is-invalid @enderror" name="ssn_card_num" maxlength="20" value="{{ old('ssn_card_num') }}">
                            @error('ssn_card_num')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                        <div class="form-group">
                            <label for="cibil_score" class="form-label required">CIBIL Score</label>
                            <input type="number" class="form-control @error('cibil_score') is-invalid @enderror" name="cibil_score" min="0" max="999" value="{{ old('cibil_score') }}">
                            @error('cibil_score')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>



                        <div class="form-group">
                            <label for="profession" class="form-label required">Profession</label>
                            <input type="text" class="form-control @error('profession') is-invalid @enderror" name="profession" value="{{ old('profession') }}">
                            @error('profession')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                        <div class="form-group">
                            <label for="employment_status" class="form-label required">Employment Status</label>
                            <input type="text" class="form-control @error('employment_status') is-invalid @enderror" name="employment_status" value="{{ old('employment_status') }}">
                            @error('employment_status')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>

                    </div>
                    <div class="col-md-6">
                        <div class="form-group">
                            <label for="marital_status" class="form-label required">Marital Status</label>
                            <input type="text" class="form-control @error('marital_status') is-invalid @enderror" name="marital_status" value="{{ old('marital_status') }}">
                            @error('marital_status')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                        <div class="form-group">
                            <label for="father_name" class="form-label required">Father's Name</label>
                            <input type="text" class="form-control @error('father_name') is-invalid @enderror" name="father_name" value="{{ old('father_name') }}">
                            @error('father_name')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>



                        <div class="form-group">
                            <label for="mother_name" class="form-label required">Mother's Name</label>
                            <input type="text" class="form-control @error('mother_name') is-invalid @enderror" name="mother_name" value="{{ old('mother_name') }}">
                            @error('mother_name')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                        <div class="form-group">
                            <label for="male_siblings" class="form-label required">Number of Male Siblings</label>
                            <input type="number" class="form-control @error('male_siblings') is-invalid @enderror" name="male_siblings" min="0" value="{{ old('male_siblings') }}">
                            @error('male_siblings')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>


                        <div class="form-group">
                            <label for="female_siblings" class="form-label required">Number of Female Siblings</label>
                            <input type="number" class="form-control @error('female_siblings') is-invalid @enderror" name="female_siblings" min="0" value="{{ old('female_siblings') }}">
                            @error('female_siblings')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                        <div class="form-group">
                            <label for="consent_to_contact" class="form-label required">Consent to Contact</label>
                            <select class="form-select @error('consent_to_contact') is-invalid @enderror" name="consent_to_contact">
                                <option value="1" {{ old('consent_to_contact') == '1' ? 'selected' : '' }}>Yes</option>
                                <option value="0" {{ old('consent_to_contact') == '0' ? 'selected' : '' }}>No</option>
                            </select>
                            @error('consent_to_contact')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>

                        <div class="form-group">
                            <label for="medical_billing_address" class="form-label required">Medical Billing Address</label>
                            <input type="text" class="form-control @error('medical_billing_address') is-invalid @enderror" name="medical_billing_address" value="{{ old('medical_billing_address') }}">
                            @error('medical_billing_address')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                        <div class="form-group">
                            <label for="current_medications" class="form-label required">Current Medications</label>
                            <input type="text" class="form-control @error('current_medications') is-invalid @enderror" name="current_medications" value="{{ old('current_medications') }}">
                            @error('current_medications')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>

                        <div class="form-group">
                            <label for="previous_health_history" class="form-label required">Previous Health History</label>
                            <input type="text" class="form-control @error('previous_health_history') is-invalid @enderror" name="previous_health_history" value="{{ old('previous_health_history') }}">
                            @error('previous_health_history')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                        <div class="form-group">
                            <label for="consent_to_treatment" class="form-label required">Consent to Treatment</label>
                            <select class="form-select @error('consent_to_treatment') is-invalid @enderror" name="consent_to_treatment" required>
                                <option value="1" {{ old('consent_to_treatment') == '1' ? 'selected' : '' }}>Yes</option>
                                <option value="0" {{ old('consent_to_treatment') == '0' ? 'selected' : '' }}>No</option>
                            </select>
                            @error('consent_to_treatment')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>

                        <div class="form-group">
                            <label for="allergies" class="form-label required">Allergies</label>
                            <input type="hidden" name="unique_id" id="unique_id">
                            <input type="text" class="form-control @error('allergies') is-invalid @enderror" name="allergies" value="{{ old('allergies') }}">
                            @error('allergies')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                        <div class="form-group">
                        <label for="organ_donors" class="form-label">
                                    Organ Donors (Optional)
                                </label>
                                <div class="form-check">
                                    <input type="checkbox" class="form-check-input @error('organ_donors') is-invalid @enderror" id="organ_donors" name="organ_donors" value="1" {{ old('organ_donors') ? 'checked' : '' }}>
                                    <label class="form-check-label" for="organ_donors">
                          <i class="mdi mdi-hand-heart menu-icon"></i> I am an organ donor
                                    </label>
                                </div>
                                @error('organ_donors')
                                <span class="text-danger">{{ $message }}</span>
                                @enderror
                                    </div>
                        <div class="form-group">
                            <label for="photo" class="form-label required">Photo</label>
                            <input type="file" class="form-control @error('photo') is-invalid @enderror" name="photo" accept="image/*" value="{{ old('photo') }}">
                            @error('photo')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>

                        <div class="form-group">
                            <label for="drivers_license" class="form-label required">Driver s License</label>
                            <input type="file" class="form-control @error('drivers_license') is-invalid @enderror" name="drivers_license" accept="image/*" value="{{ old('drivers_license') }}">
                            @error('drivers_license')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                        <div class="form-group">
                            <label for="aadhar_card" class="form-label required">Aadhar Card</label>
                            <input type="file" class="form-control @error('aadhar_card') is-invalid @enderror" name="aadhar_card" accept="image/*" value="{{ old('aadhar_card') }}">
                            @error('aadhar_card')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>

                        <div class="form-group">
                            <label for="ssn_card" class="form-label required">SSN Card</label>
                            <input type="file" class="form-control @error('ssn_card') is-invalid @enderror" name="ssn_card" accept="image/*" value="{{ old('ssn_card') }}">
                            @error('ssn_card')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                        <div class="form-group">
                            <label for="pan_card" class="form-label required">PAN Card</label>
                            <input type="file" class="form-control @error('pan_card') is-invalid @enderror" name="pan_card" accept="image/*" value="{{ old('pan_card') }}">
                            @error('pan_card')
                            <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                    </div>
                </div>
                <button type="submit" class="btn btn-primary me-2">Submit</button>
                <a href="{{ route('admin.patient') }}" class="btn btn-light">Cancel</a>
            </form>
        </div>
    </div>
</div>

@endsection;