@extends('layouts.app')

@section('content')
    @include('partials.home_menu.menu')
    <div class="col-sm-12" ng-controller="enquiryCtrl">
        <div class="card card-large card-body white shadow-1">
            <h2><span><img src="{{asset('css/clipboards/svg/005-clipboards-10.svg')}}" alt="clipboard"
                           width="5%"></span>Make Enquiry</h2>
            <br>
            <form method="POST" action="{{ url('/enquiry/create') }}" enctype="multipart/form-data">
                @csrf

                <div class="form-group row">

                    <div class="col-md-12">
                        <label for="payment_method" class="font-weight-bold">Item Name</label>

                        <input id="name" type="text" placeholder="Item Name"
                               class="form-control{{ $errors->has('name') ? ' is-invalid' : '' }}" name="name"
                               value="{{ old('name') }}" required autofocus>

                        @if ($errors->has('name'))
                            <span class="invalid-feedback">
                                        <strong>{{ $errors->first('name') }}</strong>
                                    </span>
                        @endif
                    </div>
                </div>
                <div class="row">
                    <div class="col-md-6">
                        <label for="payment_method" class="font-weight-bold">Enquiry Type</label>

                        <select id="type"
                                class="form-control{{ $errors->has('type') ? ' is-invalid' : '' }}"
                                required autofocus name="type" ng-model="type">
                            <option value="">Select Enquiry Type</option>
                            @foreach($items as $item)
                                <option value="{{$item->id}}" @if(old('type') == $item->id) selected @endif>{{$item->name}}</option>

                            @endforeach
                        </select>

                        @if ($errors->has('type'))
                            <span class="invalid-feedback">
                                        <strong>{{ $errors->first('type') }}</strong>
                                    </span>
                        @endif
                    </div>
                    <div class="col-md-6">
                        <label for="payment_method" class="font-weight-bold">Payment Method</label>
                        <select id="payment_method"
                                class="form-control{{ $errors->has('type') ? ' is-invalid' : '' }}"
                                required autofocus name="payment_method" ng-model="payment_method">
                            <option value="" >Select Payment Method</option>
                            <option value="Medical Aid" @if(old('payment_method') == "Medical Aid") selected @endif >Medical Aid</option>
                            <option value="Cash" @if(old('payment_method') == "Cash") selected @endif>Cash On Delivery</option>
                            <option value="EcoCash" @if(old('payment_method') == "EcoCash") selected @endif>EcoCash</option>
                            <option value="OneMoney" @if(old('payment_method') == "OneMoney") selected @endif>OneMoney</option>
                            <option value="Visa" @if(old('payment_method') == "Visa") selected @endif>Visa/MasterCard</option>
                        </select>

                        @if ($errors->has('payment_method'))
                            <span class="invalid-feedback">
                                        <strong>{{ $errors->first('payment_method') }}</strong>
                                    </span>
                        @endif
                    </div>
                </div>
                <br>


                <div class="form-group row">

                    <div class="col-md-12">
                        <label for="payment_method" class="font-weight-bold">Description</label>

                        <textarea placeholder="Description"
                                      class="form-control{{ $errors->has('description') ? ' is-invalid' : '' }}"
                                      name="description"
                                      required>
                                {{ old('description') }}
                            </textarea>

                        @if ($errors->has('description'))
                            <span class="invalid-feedback">
                                        <strong>{{ $errors->first('description') }}</strong>
                                    </span>
                        @endif
                    </div>
                </div>
                <div class="form-group row">

                    <div class="col-md-6">
                        <label for="payment_method" class="font-weight-bold">Billing Address</label>

                        <textarea placeholder="Address"
                                      class="form-control{{ $errors->has('address') ? ' is-invalid' : '' }}"
                                      name="address"
                                      required>{{ old('address') }}</textarea>

                        @if ($errors->has('address'))
                            <span class="invalid-feedback">
                                        <strong>{{ $errors->first('address') }}</strong>
                                    </span>
                        @endif
                    </div>
                    <div class="col-md-6">
                        <label for="delivery_address" class="font-weight-bold">Delivery Address</label>

                        <textarea id="delivery_address" placeholder="Delivery Address"
                                      class="form-control{{ $errors->has('delivery_address') ? ' is-invalid' : '' }}"
                                      name="delivery_address"
                                      required>{{ old('delivery_address') }}</textarea>

                        @if ($errors->has('address'))
                            <span class="invalid-feedback">
                                        <strong>{{ $errors->first('address') }}</strong>
                                    </span>
                        @endif
                    </div>
                </div>
                <div class="row" ng-if="type == '{{$prescription}}'">
                    <div class="col-md-6" class="font-weight-bold">
                        <label for="prescription_file" class="font-weight-bold">Prescription</label>

                        <input id="prescription_file" type="file" placeholder="Prescription"
                               class="form-control{{ $errors->has('file') ? ' is-invalid' : '' }}"
                               name="prescription_file"
                               value="{{ old('prescription_file') }}"
                               required
                        >

                        @if ($errors->has('prescription_file'))
                            <span class="invalid-feedback">
                                        <strong>{{ $errors->first('prescription_file') }}</strong>
                                    </span>
                        @endif
                    </div>
                </div>

                <br>
                <hr>
                <div ng-if="payment_method == 'Medical Aid'">
                    <h2>Medical Aid Details</h2>
                    <br>
                    <div class="form-group row">
                        <div class="col-md-12">
                            <label for="medical_aid_name" class="font-weight-bold">Medical Aid Name</label>

                            <select name="medical_aid_name" id="medical_aid_name" class="form-control{{ $errors->has('medical_aid_name') ? ' is-invalid' : '' }}">
                                <option value="">Select your medical aid</option>
                                @foreach($medical_aid as $item)
                                    <option value="{{$item->name}}" @if(old('medical_aid_name') == $item->name) selected @endif>{{$item->name}}</option>
                                @endforeach
                            </select>
                        </div>

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

                        <div class="col-md-6">
                            <label for="payment_method" class="font-weight-bold">Principal Member's Name</label>

                            <input id="medical_aid_name" type="text" placeholder="Medical Aid Name"
                                   class="form-control{{ $errors->has('medical_aid_member_name') ? ' is-invalid' : '' }}" name="medical_aid_member_name"
                                   value="{{ old('medical_aid_member_name') }}" required autofocus>

                            @if ($errors->has('medical_aid_member_name'))
                                <span class="invalid-feedback">
                                        <strong>{{ $errors->first('medical_aid_member_name') }}</strong>
                                    </span>
                            @endif
                        </div>

                        <div class="col-md-6">
                            <label for="payment_method" class="font-weight-bold">Membership Number</label>

                            <input id="medical_aid_number" type="text" placeholder="Medical Aid Number"
                                   class="form-control{{ $errors->has('medical_aid_number') ? ' is-invalid' : '' }}" name="medical_aid_number"
                                   value="{{ old('medical_aid_number') }}" required autofocus>

                            @if ($errors->has('medical_aid_number'))
                                <span class="invalid-feedback">
                                        <strong>{{ $errors->first('medical_aid_number') }}</strong>
                                    </span>
                            @endif
                        </div>
                    </div>
                    <div class="form-group row">

                        <div class="col-md-6">
                            <label for="payment_method" class="font-weight-bold">Medical Aid Plan</label>

                            <input id="medical_aid_plan" type="text" placeholder="Medical Aid Plan"
                                   class="form-control{{ $errors->has('medical_aid_plan') ? ' is-invalid' : '' }}" name="medical_aid_plan"
                                   value="{{ old('medical_aid_plan') }}" required autofocus>

                            @if ($errors->has('medical_aid_plan'))
                                <span class="invalid-feedback">
                                        <strong>{{ $errors->first('medical_aid_plan') }}</strong>
                                    </span>
                            @endif
                        </div>
                        <div class="col-md-6">
                            <label for="payment_method" class="font-weight-bold">Medical Aid Suffix</label>

                            <input id="name" type="text" placeholder="Medical Aid Suffix"
                                   class="form-control{{ $errors->has('medical_aid_patient_suffix') ? ' is-invalid' : '' }}" name="medical_aid_patient_suffix"
                                   value="{{ old('medical_aid_patient_suffix') }}" required autofocus>

                            @if ($errors->has('medical_aid_patient_suffix'))
                                <span class="invalid-feedback">
                                        <strong>{{ $errors->first('medical_aid_patient_suffix') }}</strong>
                                    </span>
                            @endif
                        </div>
                    </div>
                    <div class="form-group row">
                        <div class="col-md-12">
                            <label for="medical_aid_relationship_to_member" class="font-weight-bold">Relationship to member</label>

                            <select name="medical_aid_relationship_to_member" id="medical_aid_relationship_to_member" class="form-control{{ $errors->has('medical_aid_relationship_to_member') ? ' is-invalid' : '' }}">
                                <option value="">Select your relationship</option>
                                <option value="Self" @if(old('medical_aid_relationship_to_member') == "Self") selected @endif >Self</option>
                                <option value="Wife" @if(old('medical_aid_relationship_to_member') == "Wife") selected @endif>Wife</option>
                                <option value="Husband" @if(old('medical_aid_relationship_to_member') == "Husband") selected @endif>Husband</option>
                                <option value="Son" @if(old('medical_aid_relationship_to_member') == "Son") selected @endif>Son</option>
                                <option value="Mother" @if(old('medical_aid_relationship_to_member') == "Mother") selected @endif>Mother</option>
                                <option value="Father" @if(old('medical_aid_relationship_to_member') == "Father") selected @endif>Father</option>
                                <option value="Brother" @if(old('medical_aid_relationship_to_member') == "Brother") selected @endif>Brother</option>
                                <option value="Sister" @if(old('medical_aid_relationship_to_member') == "Sister") selected @endif>Sister</option>
                                <option value="Cousin" @if(old('medical_aid_relationship_to_member') == "Cousin") selected @endif>Cousin</option>
                                <option value="Aunt" @if(old('medical_aid_relationship_to_member') == "Aunt") selected @endif>Aunt</option>
                                <option value="Uncle" @if(old('medical_aid_relationship_to_member') == "Uncle") selected @endif>Uncle</option>
                                <option value="Grand-Father" @if(old('medical_aid_relationship_to_member') == "Grand-Father") selected @endif>Grand-Father</option>
                                <option value="Grand-Mother" @if(old('medical_aid_relationship_to_member') == "Grand-Mother") selected @endif>Grand-Mother</option>
                            </select>

                        </div>
                    </div>

                </div>
<!--
                <div ng-show="payment_method == 'Medical Aid'">
                    <div class="form-group row">

                        <div class="col-md-12">
                            <label for="medical_aid_file" class="font-weight-bold">Medical Aid File</label>

                            <input id="medical_aid_file" type="file" placeholder="Medical Aid"
                                   class="form-control{{ $errors->has('medical_aid_file') ? ' is-invalid' : '' }}"
                                   name="medical_aid_file"
                                   value="{{ old('medical_aid_file') }}">

                            @if ($errors->has('medical_aid_file'))
                                <span class="invalid-feedback">
                                        <strong>{{ $errors->first('medical_aid_file') }}</strong>
                                    </span>
                            @endif
                        </div>
                    </div>

                </div>
-->





                <div class="form-group row mb-0">
                    <div class="col-md-12">
                        <button type="submit" class="btn btn-primary btn-block">
                            Make Enquiry
                        </button>
                    </div>
                </div>

            </form>

        </div>

    </div>

@endsection