{{--<div class="alert alert-danger display-none" id="customValidationErrorsBox"></div>--}}
<div class="row mb-5">
    <div class="col-md-6">
        <div class="form-group mb-5">
            {{ Form::label('first_name', __('messages.user.first_name').':', ['class' => 'form-label']) }}<span
                    class="required"></span>
            {{ Form::text('first_name', null, ['class' => 'form-control', 'required', 'id' => 'firstName','tabindex' => '1']) }}
        </div>
    </div>
    <div class="col-md-6">
        <div class="form-group mb-5">
            {{ Form::label('last_name', __('messages.user.last_name').':', ['class' => 'form-label']) }}<span
                    class="required"></span>
            {{ Form::text('last_name', null, ['class' => 'form-control', 'required', 'tabindex' => '2']) }}
        </div>
    </div>
    <div class="col-md-6">
        <div class="form-group mb-5">
            {{ Form::label('email', __('messages.user.email').':', ['class' => 'form-label']) }}<span
                    class="required"></span>
            {{ Form::email('email', null, ['class' => 'form-control', 'required', 'tabindex' => '3']) }}
        </div>
    </div>
    <div class="col-md-6">
        <div class="form-group mb-5">
            {{ Form::label('dob', __('messages.user.dob').':', ['class' => 'form-label']) }}
            {{ Form::text('dob', null, ['class' => (getLoggedInUser()->theme_mode) ? 'form-control bg-light patientBirthDate' : 'form-control bg-white patientBirthDate', 'autocomplete' => 'off', 'tabindex' => '4']) }}
        </div>
    </div>
    <div class="col-md-6">
        <div class="form-group mobile-overlapping  mb-5">
            {{ Form::label('phone', __('messages.user.phone').':', ['class' => 'form-label']) }}<span
                    class="required"></span><br>
            {{ Form::tel('phone', null, ['class' => 'form-control phoneNumber', 'id' => 'phoneNumber', 'required', 'onkeyup' => 'if (/\D/g.test(this.value)) this.value = this.value.replace(/\D/g,"")', 'tabindex' => '5']) }}
            {{ Form::hidden('prefix_code',null,['class'=>'prefix_code']) }}
            {{ Form::hidden('country_iso', null, ['class' => 'country_iso']) }}
            <span class="text-success valid-msg d-none fw-400 fs-small mt-2" id="valid-msg">✓ &nbsp; {{__('messages.valid')}}</span>
            <span class="text-danger error-msg d-none fw-400 fs-small mt-2" id="error-msg"></span>
        </div>
    </div>
    <div class="col-md-3">
        <div class="form-group mb-5">
            {{ Form::label('gender', __('messages.user.gender').':', ['class' => 'form-label']) }}<span
                    class="required"></span> &nbsp;<br>
            <div class="d-flex align-items-center">
                <div class="form-check">
                    <label class="form-label" for="malePatient">{{ __('messages.user.male') }}</label>&nbsp;&nbsp;
                    {{ Form::radio('gender', '0', true, ['class' => 'form-check-input', 'tabindex' => '6','id'=>'malePatient']) }}
                    &nbsp;
                </div>
                <div class="form-check">
                    <label class="form-label" for="femalePatient">{{ __('messages.user.female') }}</label>
                    {{ Form::radio('gender', '1', false, ['class' => 'form-check-input', 'tabindex' => '7','id'=>'femalePatient']) }}
                </div>
            </div>
        </div>
    </div>
    <div class="col-md-3">
        <div class="form-group mb-5">
            {{ Form::label('status', __('messages.common.status').':', ['class' => 'form-label']) }}
            <div class="form-check form-switch">
                <input class="form-check-input is-active" name="status" type="checkbox" value="1"
                       tabindex="8" checked>
            </div>
        </div>
    </div>
    <div class="col-md-6">
        <div class="form-group mb-5">
            {{ Form::label('blood_group', __('messages.user.blood_group').':', ['class' => 'form-label']) }}
            {{ Form::select('blood_group', $bloodGroup, null, ['class' => 'form-select', 'id' => 'bloodGroupPatient', 'placeholder' => __('messages.user.select_blood_group'), 'data-control' => 'select2', 'tabindex' => "9"]) }}
        </div>
    </div>
    <div class="col-md-3">
        <div class="form-group mb-5">
            {{ Form::label('password', __('messages.user.password').':', ['class' => 'form-label']) }}
            <span class="required"></span>
            {{ Form::password('password', ['class' => 'form-control','required','min' => '6','max' => '10', 'tabindex' => '10']) }}
        </div>
    </div>
    <div class="col-md-3">
        <div class="form-group mb-5">
            {{ Form::label('password_confirmation', __('messages.user.password_confirmation').':', ['class' => 'form-label']) }}
            <span class="required"></span>
            {{ Form::password('password_confirmation', ['class' => 'form-control','required','min' => '6','max' => '10', 'tabindex' => '11']) }}
        </div>
    </div>
    <div class="form-group col-md-4 mb-5">
        <div class="row2">
            {{ Form::label('image', __('messages.profile.profile').':', ['class' => 'form-label']) }}
            <div class="d-block">
                
                    <div class="image-picker">
                        <div class="image previewImage" id="PatientPreviewImage"
                        {{$style}}"{{$background}} url({{ asset('assets/img/avatar.png') }}">
                    <span class="picker-edit rounded-circle text-gray-500 fs-small" data-bs-toggle="tooltip"
                          data-placement="top"
                          data-bs-original-title="{{__('messages.profile.change_Profile')}}">
                                    <label>
                                    <i class="fa-solid fa-pen" id="profileImageIcon"></i>
                                        <input type="file" id="" name="image"
                                               class="image-upload d-none" accept=".png, .jpg, .jpeg, .gif, .webp"/>
                                        <input type="hidden" name="avatar_remove"/>
                                    </label>
                                </span>
                    </div>
            </div>
        </div>
    </div>
</div>
</div>
<hr>
<div class="row mt-3 mb-5">
    <div class="col-md-12 mb-3">
        <h5>{{ __('messages.user.address_details') }}</h5>
    </div>
    <div class="col-md-6">
        <div class="form-group mb-5">
            {{ Form::label('address1', __('messages.user.address1').':', ['class' => 'form-label']) }}
            {{ Form::text('address1', null, ['class' => 'form-control']) }}
        </div>
    </div>
    <div class="col-md-6">
        <div class="form-group mb-5">
            {{ Form::label('address2', __('messages.user.address2').':', ['class' => 'form-label']) }}
            {{ Form::text('address2', null, ['class' => 'form-control']) }}
        </div>
    </div>
    <div class="col-md-3">
        <div class="form-group mb-5">
            {{ Form::label('city', __('messages.user.city').':', ['class' => 'form-label']) }}
            {{ Form::text('city', null, ['class' => 'form-control']) }}
        </div>
    </div>
    <div class="col-md-3">
        <div class="form-group mb-5">
            {{ Form::label('zip', __('messages.user.zip').':', ['class' => 'form-label']) }}
            {{ Form::text('zip', null, ['class' => 'form-control', 'maxlength' => '6','minlength' => '6']) }}
        </div>
    </div>
</div>
<hr>
<div class="row mt-3 mb-5">
    <div class="col-md-12 mb-3">
        <h5>{{ __('messages.setting.social_details') }}</h5>
    </div>

    <!-- Facebook URL Field -->
    <div class="form-group col-sm-6 mb-5">
        {{ Form::label('facebook_url', __('messages.facebook_url').':', ['class' => 'form-label']) }}
        {{ Form::text('facebook_url', null, ['class' => 'form-control patientFacebookUrl', 'onkeypress' => 'return avoidSpace(event);']) }}
    </div>

    <!-- Twitter URL Field -->
    <div class="form-group col-sm-6 mb-5">
        {{ Form::label('twitter_url', __('messages.twitter_url').':', ['class' => 'form-label']) }}
        {{ Form::text('twitter_url', null, ['class' => 'form-control patientTwitterUrl', 'onkeypress' => 'return avoidSpace(event);']) }}
    </div>

    <!-- Instagram URL Field -->
    <div class="form-group col-sm-6 mb-5">
        {{ Form::label('instagram_url', __('messages.instagram_url').':', ['class' => 'form-label']) }}
        {{ Form::text('instagram_url', null, ['class' => 'form-control patientInstagramUrl', 'onkeypress' => 'return avoidSpace(event);']) }}
    </div>

    <!-- LinkedIn URL Field -->
    <div class="form-group col-sm-6 mb-5">
        {{ Form::label('linkedIn_url', __('messages.linkedIn_url').':', ['class' => 'form-label']) }}
        {{ Form::text('linkedIn_url', null, ['class' => 'form-control patientLinkedInUrl', 'onkeypress' => 'return avoidSpace(event);']) }}
    </div>

</div>
<div class="d-flex justify-content-end">
    {{ Form::submit(__('messages.common.save'), ['class' => 'btn btn-primary me-2','id' => 'btnSave']) }}
    <a href="{{ route('patients.index') }}"
       class="btn btn-secondary">{!! __('messages.common.cancel') !!}</a>
</div>