@extends('layouts.templatemedflix')
//
@section('content_ticketview')

<div class="card">
    <div class="card-header">
        <h3>Añadir Ticket</h3>
    </div>
                            
    <div class="card-body">
        <br>
        <form method="post" action="{{ url('tickets/') }}" enctype="multipart/form-data">
        {{ csrf_field() }} 

            <div class="container">

                <div class="form-row">
                    <div class="form-group col-md-3">
                        {{-- <label for="inputEmail4">Nombre</label> --}}
                        <input type="text" class="form-control" id="inputEmail4" placeholder="Nombre" name="first_name">
                    </div>
                    <div class="form-group col-md-3">
                        {{-- <label for="inputPassword4">Apellido Paterno</label> --}}
                        <input type="text" class="form-control" id="inputPassword4" placeholder="Apellido Paterno" name="last_name">
                    </div>
                    <div class="form-group col-md-3">
                        {{-- <label for="inputPassword4">Apellido Materno</label> --}}
                        <input type="text" class="form-control" id="inputPassword4" placeholder="Apellido Materno" name="maternal_lastname">
                    </div>
                </div>

                <div class="form-row">
                    <div class="form-group col-md-2">
                        <label for="inputState">Fecha de Nacimiento</label>
                        <input name="birthdate" type="date" class="form-control" id="inputCity">
                    </div>
                    <div class="form-group col-md-1">
                        <label for="inputState">Sexo</label>
                        <select id="inputState" class="form-control" type="text" name="sex">
                            <option value="F">F</option>
                            <option value="M">M</option>
                        </select>
                    </div>
                </div>   
                                            
                <div class="form-row">
                    <div class="form-group col-md-3">
                        {{-- <label for="inputState">Email</label> --}}
                        <input name="email" type="email" class="form-control" id="inputCity" placeholder="Email">
                    </div>
                    <div class="form-group col-md-3">
                        {{-- <label for="">Telefono</label> --}}
                        <input name="phone" type="text" class="form-control" id="inputPassword4" placeholder="Telefono">
                    </div>
                    <div class="form-group col-md-3">
                        {{-- <label for="">Telefono Alterno</label> --}}
                        <input name="alt_phone" type="text" class="form-control" id="inputPassword4" placeholder="Telefono Alterno">
                    </div>
                </div>

                <h3>Necesitamos su identificacion</h3>
                <div class="form-row">
                    <div class="custom-file col-md-3">
                        <input name="identification" type="file" class="custom-file-input" id="customFile">
                        <label class="custom-file-label" for="customFile">ID</label>
                    </div>
                </div>
                <br>
                <hr>
                <br>
                
                <h3>Plan Medico Primario</h3>
                <div class="form-row">
                    <div class="form-group col-my-3">
                        <select class="custom-select mr-sm medplan" type="text" name="plan_name" required>
                            <option selected>Plan Medico</option>
                            @foreach ($md_list as $md)
                            <option value="{{$md->md_name}}">{{ $md->md_name }}</option>                                                   
                            @endforeach
                        </select>
                    </div>
                    <div class="form-group col-md-3">
                        {{-- <label for=""></label> --}}
                        <input name="insured_name" type="text" class="form-control" id="inputPassword4" placeholder="Nombre Del Asegurado">
                    </div>

                </div>
                <div class="form-row">
                                    
                    <div class="form-group col-md-3">
                        {{-- <label for=""></label> --}}
                        <input name="insured_number" id="mp-id" type="text" class="form-control mp-id" placeholder="Numero Del Asegurado" required>
                    </div>
                    <div class="form-group col-md-3">
                        {{-- <label for=""></label> --}}
                        <input name="group_number" type="text" class="form-control mp-group" placeholder="Numero De Grupo" required>
                    </div>
                    <div class="custom-file col-md-3">
                        <input name="card_img" type="file" class="custom-file-input" id="customFile">
                        <label class="custom-file-label" for="customFile">Foto Plan Medico Primario</label>
                    </div>
                </div>
                <div class="col-8">
                    <div class="custom-control custom-checkbox custom-control-inline">
                        <input name="aplica" type="checkbox" class="form-check-input checkbox" id="checkboxid" value="0" onclick="checkaplica()"> 
                        <label>Tengo Plan Medico Secundario</label>
                    </div>
                </div>

                {{-- Seccion : Plan Medico Secudario --}}
                <h3 class="aplica" hidden>Plan Medico Secundario</h3>
                <div class="form-row">
                    <div class="form-group col-my-3">
                        <select type="text" name="plan_name2nd" class="custom-select mr-sm aplica medplan2" disabled hidden>
                            <option selected class="aplica" disabled>Plan Medico</option>
                            @foreach ($md_list as $md)
                            <option value="{{$md->md_name}}">{{ $md->md_name }}</option>                                                   
                            @endforeach
                        </select>
                    </div>

                    <div class="form-group col-md-3">
                        <input name="insured_name2nd" type="text" class="form-control aplica" placeholder="Nombre del asegurado" disabled hidden>
                    </div>

                </div>
                <div class="form-row">      
                    <div class="form-group col-md-3">
                        {{-- <label for=""></label> --}}
                        <input name="insured_number2nd" type="text" class="form-control aplica mp-id2" placeholder="Numero del asegurado" disabled hidden>
                    </div>
                    <div class="form-group col-md-3">
                        {{-- <label for=""></label> --}}
                        <input name="group_number2nd" type="text" class="form-control aplica mp-group2" placeholder="Numero de grupo" disabled hidden>
                    </div>
                    <div class="custom-file col-md-3">
                        <input name="card_img2nd" type="file" class="custom-file-input aplica" id="inputGroupFile01" disabled hidden>
                        <label class="custom-file-label aplica" for="inputGroupFile01" disabled hidden>Foto Plan Medico Secundario</label>
                    </div>
                </div>
                <hr>
                <h3>Servicios</h3>
                <div class="form-row">
                    <div class="form-group col-md-4">
                        <select name="service" class="custom-select" id="inputGroupSelect01" type="text" name="service">
                            <option selected>Servicio que solicita</option>
                            <option value="MRI">MRI</option>
                            <option value="MRA">MRA</option>
                            <option value="Dual Sorce CT">Dual Sorce CT</option>
                            <option value="CTA">CTA</option>
                            <option value="Nuclear Medicine">Nuclear Medicine</option>
                            <option value="SPECT-CT">SPECT-CT</option>
                            <option value="PET-CT">PET-CT</option>
                            <option value="DEXA-Bone Densitometry">DEXA-Bone Densitometry</option>
                            <option value="Body Composition Analysis">Body Composition Analysis</option>
                            <option value="General and Vascular Ultrasound">General and Vascular Ultrasound</option>
                            <option value="Pediatric and Adult Sedation">Pediatric and Adult Sedation</option>
                            <option value="Iodine 131 Therapy">Iodine 131 Therapy</option>
                            <option value="DaTscan">DaTscan</option>
                        </select>
                    </div>
                    <div class="form-group col-sm-2">
                        <select class="js-example-placeholder-multiple js-states custom-select" id="service-code" name="code">
                            <option></option>
                            <optgroup label="MRI">
                                <option>1520</option>
                                <option>6532</option>
                            </optgroup>  

                            <optgroup label="MRA">
                            </optgroup> 

                            <optgroup label="CTA">
                                <option>75214</option>
                                <option>6452</option>
                                <option>6540</option>
                            </optgroup>  

                            <optgroup label="Dual Sorce CT">
                                <option>5632</option>
                            </optgroup> 

                            <optgroup label="CTA">
                                <option>4879</option>
                            </optgroup>

                            <optgroup label="Nuclear Medicine">
                                <option>7854</option>
                            </optgroup>

                            <optgroup label="SPECT-CT">
                                <option>3456</option>
                            </optgroup>

                            <optgroup label="PET-CT">
                                <option>9514</option>
                            </optgroup>

                            <optgroup label="DEXA-Bone Densitometry">
                                <option>3547</option>
                            </optgroup>

                            <optgroup label="Body Composition Analysis">
                                <option>2587</option>
                            </optgroup>

                            <optgroup label="General and Vascular Ultrasound">
                            </optgroup>

                            <optgroup label="Pediatric and Adult Sedation">
                            </optgroup>

                            <optgroup label="Iodine 131 Therapy">
                            </optgroup>

                            <optgroup label="DaTscan">
                            </optgroup>
                        </select>
                    </div>
                    <div class="form-group col-md-4 custom-file">
                        <input name="medical_order" type="file" class="custom-file-input" id="inputGroupFile01" required>
                        <label class="custom-file-label" for="inputGroupFile01">Escoger Orden Medica</label>     
                    </div>
                </div>
                <input type="text" hidden value="4" name="activity">
                <button type="submit" class="btn btn-primary">Submit</button>
            </div>
        </form>
    </div>
</div>

@endsection