@extends('layouts.app')

@section('title')
{{__('Profile')}}
@endsection

@section('breadcrumb')
<div class="content-header">
  <div class="container-fluid">
    <div class="row mb-2">
        <div class="col-sm-6">
            <h1 class="m-0 text-dark">
                <i class="fa fa-user-circle"></i>
                {{__('Profile')}}
            </h1>
        </div><!-- /.col -->
      <div class="col-sm-6">
        <ol class="breadcrumb float-sm-right">
          <li class="breadcrumb-item"><a href="{{route('patient.index')}}">{{__('Home')}}</a></li>
          <li class="breadcrumb-item active">{{__('Profile')}}</li>
        </ol>
      </div><!-- /.col -->
    </div><!-- /.row -->
  </div><!-- /.container-fluid -->
</div>
@endsection

@section('content')
<div class="card card-primary">
  <div class="card-header">
    <h3 class="card-title">{{__('Edit Profile')}}</h3>
  </div>
  <!-- /.card-header -->
  <form method="POST" action="{{route('patient.profile.update')}}" enctype="multipart/form-data">
    @csrf
    <div class="card-body">
      <div class="row">

    
        <div class="col-lg-2">
    
            <div class="card card-primary">
                <div class="card-header">
                    <h5 class="text-center m-0 p-0">
                        {{__('Avatar')}}
                    </h5>
                </div>
                <div class="card-footer m-0 p-0 pt-3">
                    <div class="col-lg-12">
                        <div class="form-group">
                            <div class="input-group">
                                <div class="custom-file">
                                    <input type="file" name="avatar" class="custom-file-input" id="avatar">
                                    <label class="custom-file-label">{{__('Choose avatar')}}</label>
                                </div>
                            </div>
                        </div>
                    </div>
                </div>
                <div class="card-body m-0 p-0">
                    <div class="row">
                        <div class="col-lg-12 text-center">
                            <a href="@if(!empty($patient['avatar'])){{url('uploads/patient-avatar/'.$patient['avatar'])}}@else{{url('img/avatar.png')}}@endif" data-toggle="lightbox" data-title="Avatar">
                                <img src="@if(!empty($patient['avatar'])){{url('uploads/patient-avatar/'.$patient['avatar'])}}@else{{url('img/avatar.png')}}@endif"  class="img-thumbnail" id="patient_avatar" alt="">
                            </a>
                        </div>
                    </div>
                </div>
                <div class="card-footer">
                    <button type="button" class="btn btn-danger btn-sm float-right" id="delete_avatar" style="width:100%">
                        <i class="fa fa-trash"></i>
                    </button>
                </div>
                
            </div>
    
        </div>
    
        <div class="col-lg-10">
    
            <div class="row">
    
                <div class="col-lg-4">
                    <div class="form-group">
                        <div class="input-group mb-3">
                            <div class="input-group-prepend">
                            <span class="input-group-text" id="basic-addon1">
                                <i class="fa fa-user"></i>
                            </span>
                            </div>
                            <input type="text" class="form-control" placeholder="{{__('Patient Name')}}" name="name" id="name" @if(isset($patient)) value="{{$patient->name}}" @elseif(old('name')) value="{{old('name')}}" @endif readonly>
                        </div>
                    </div>
                </div>
                <div class="col-lg-4">
                    <div class="form-group">
                        <div class="input-group mb-3">
                            <div class="input-group-prepend">
                            <span class="input-group-text" id="basic-addon1">
                                <i class="fa fa-user"></i>
                            </span>
                            </div>
                            <input type="text" class="form-control" placeholder="{{__('Patient\'s Middle Name')}}" name="middle_name" id="middlename" @if(isset($patient)) value="{{$patient->middle_name}}" @elseif(old('middle_name')) value="{{old('middle_name')}}" @endif style='text-transform:uppercase' readonly>
                        </div>
                    </div>
                </div>
                <div class="col-lg-4">
                    <div class="form-group">
                        <div class="input-group mb-3">
                            <div class="input-group-prepend">
                            <span class="input-group-text" id="basic-addon1">
                                <i class="fa fa-user"></i>
                            </span>
                            </div>
                            <input type="text" class="form-control" placeholder="{{__('Patient\'s Last Name')}}" name="last_name" id="lastname" @if(isset($patient)) value="{{$patient->last_name}}" @elseif(old('last_name')) value="{{old('last_name')}}" @endif required style='text-transform:uppercase' readonly>
                        </div>
                    </div>
                </div>
                <div class="col-lg-6">
                    <div class="form-group">
                        <div class="input-group mb-3">
                            <div class="input-group-prepend">
                            <span class="input-group-text" id="basic-addon1">
                            <i class="fas fa-sort-numeric-up-alt"></i>
                            </span>
                            </div>
                            <input type="number" class="form-control" placeholder="{{__('For Multiple Birth')}}" name="birth_count" id="birth_count" @if(isset($patient)) value="{{$patient->birth_count}}" @elseif(old('birth_count')) value="{{old('birth_count')}}"  @endif  readonly>
                        </div>
                    </div>
                </div>
                <div class="col-lg-6">
                    <div class="form-group">
                        <div class="form-group">
                            <div class="input-group mb-3">
                                <div class="input-group-prepend">
                                <span class="input-group-text" id="basic-addon1">
                                    <i class="fas fa-baby"></i>
                                </span>
                                </div>
                                <input autocomplete="off" max="2025-12-11" type="date" class="form-control dob_datepicker" placeholder="{{__('Date of birth')}}" name="dob" id="dob"  @if(isset($patient)) value="{{$patient['dob']}}" @elseif(old('dob')) value="{{old('dob')}}" @endif readonly>
                            </div>
                        </div>
                    </div>
                </div>
                <div class="col-lg-6">
                    <div class="form-group">
                        <div class="input-group mb-3">
                        <div class="input-group-prepend">
                                    <span class="input-group-text" id="basic-addon1">
                                    <i class="fas fa-baby"></i>
                                    </span>
                                </div>
                                <input type="number" class="form-control" name="age" id="age" placeholder="{{__('Age')}}" @if(!isset($patient)&&old('age')) value="{{old('age')}}" @endif readonly>
                        </div>
                    </div>
                </div>

                <div class="col-lg-6">
                    <div class="form-group">
                        <div class="input-group mb-3">
                    
                                <select class="form-control" name="age_unit" id="age_unit" disabled>
                                    <option value="" disabled selected>{{__('Select age unit')}}</option>
                                    <option value="years" @if(!isset($patient)&&old('age_unit')=='years') selected @endif>{{__('Years')}}</option>
                                    <option value="months" @if(!isset($patient)&&old('age_unit')=='months') selected @endif>{{__('Months')}}</option>
                                    <option value="days" @if(!isset($patient)&&old('age_unit')=='days') selected @endif>{{__('Days')}}</option>
                                </select>
                            
                        </div>
                    </div>
                </div>

                <div class="col-lg-6">
                    <div class="form-group">
                        <div class="form-group">
                            <div class="input-group mb-3">
                                <div class="input-group-prepend">
                                <span class="input-group-text" id="basic-addon1">
                                    <i class="fas fa-mars"></i>
                                </span>
                                </div>
                                <select class="form-control" name="gender" placeholder="{{__('Gender')}}" id="gender" disabled>
                                    <option value="" disabled selected>{{__('Gender')}}</option>
                                    <option value="male"  @if(isset($patient)&&$patient['gender']=='male') selected @elseif(old('gender')=='male') selected  @endif>{{__('Male')}}</option>
                                    <option value="female"  @if(isset($patient)&&$patient['gender']=='female') selected @elseif(old('gender')=='female') selected @endif>{{__('Female')}}</option>
                                    <option value="ambiguous"  @if(isset($patient)&&$patient['gender']=='ambiguous') selected @elseif(old('gender')=='ambiguous') selected @endif>{{__('Ambiguous')}}</option>
                                </select>
                            </div>
                        </div>
                    </div>
                </div>

                <div class="col-lg-6">
                    <div class="form-group">
                        <div class="input-group mb-3">
                            <div class="input-group-prepend">
                            <span class="input-group-text" id="basic-addon1">
                                <i class="fas fa-flag"></i>
                            </span>
                            </div>
                            <!-- <input type="text" class="form-control" placeholder="{{__('Nationality')}}" name="nationality" id="nationality" @if(isset($patient)) value="{{$patient->nationality}}" @elseif(old('nationality')) selected" @endif > -->
                            <select name="nationality" id="nationality" class="form-control" >
                                <option disabled>-- select nationality --</option>
                                <option value="afghan" @if(isset($patient) && $patient['nationality'] == 'afghan') selected @elseif(old('nationality') && old('nationality') == 'afghan') selected" @endif >Afghan</option>
                                <option value="albanian" @if(isset($patient) && $patient['nationality'] == 'albanian') selected @elseif(old('nationality') && old('nationality') == 'albanian') selected" @endif>Albanian</option>
                                <option value="algerian" @if(isset($patient) && $patient['nationality'] == 'algerian') selected @elseif(old('nationality') && old('nationality') == 'algerian') selected" @endif>Algerian</option>
                                <option value="american" @if(isset($patient) && $patient['nationality'] == 'american') selected @elseif(old('nationality') && old('nationality') == 'american') selected" @endif>American</option>
                                <option value="andorran" @if(isset($patient) && $patient['nationality'] == 'andorran') selected @elseif(old('nationality') && old('nationality') == 'andorran') selected" @endif>Andorran</option>
                                <option value="angolan" @if(isset($patient) && $patient['nationality'] == 'angolan') selected @elseif(old('nationality') && old('nationality') == 'angolan') selected" @endif>Angolan</option>
                                <option value="antiguans" @if(isset($patient) && $patient['nationality'] == 'antiguans') selected @elseif(old('nationality') && old('nationality') == 'antiguans') selected" @endif>Antiguans</option>
                                <option value="argentinean" @if(isset($patient) && $patient['nationality'] == 'argentinean') selected @elseif(old('nationality') && old('nationality') == 'argentinean') selected" @endif>Argentinean</option>
                                <option value="armenian" @if(isset($patient) && $patient['nationality'] == 'armenian') selected @elseif(old('nationality') && old('nationality') == 'armenian') selected" @endif>Armenian</option>
                                <option value="australian" @if(isset($patient) && $patient['nationality'] == 'australian') selected @elseif(old('nationality') && old('nationality') == 'australian') selected" @endif>Australian</option>
                                <option value="austrian" @if(isset($patient) && $patient['nationality'] == 'austrian') selected @elseif(old('nationality') && old('nationality') == 'austrian') selected" @endif>Austrian</option>
                                <option value="azerbaijani" @if(isset($patient) && $patient['nationality'] == 'azerbaijani') selected @elseif(old('nationality') && old('nationality') == 'azerbaijani') selected" @endif>Azerbaijani</option>
                                <option value="bahamian" @if(isset($patient) && $patient['nationality'] == 'bahamian') selected @elseif(old('nationality') && old('nationality') == 'bahamian') selected" @endif>Bahamian</option>
                                <option value="bahraini" @if(isset($patient) && $patient['nationality'] == 'bahraini') selected @elseif(old('nationality') && old('nationality') == 'bahraini') selected" @endif>Bahraini</option>
                                <option value="bangladeshi" @if(isset($patient) && $patient['nationality'] == 'bangladeshi') selected @elseif(old('nationality') && old('nationality') == 'bangladeshi') selected" @endif>Bangladeshi</option>
                                <option value="barbadian" @if(isset($patient) && $patient['nationality'] == 'barbadian') selected @elseif(old('nationality') && old('nationality') == 'barbadian') selected" @endif>Barbadian</option>
                                <option value="barbudans" @if(isset($patient) && $patient['nationality'] == 'barbudans') selected @elseif(old('nationality') && old('nationality') == 'barbudans') selected" @endif>Barbudans</option>
                                <option value="batswana" @if(isset($patient) && $patient['nationality'] == 'batswana') selected @elseif(old('nationality') && old('nationality') == 'batswana') selected" @endif>Batswana</option>
                                <option value="belarusian" @if(isset($patient) && $patient['nationality'] == 'belarusian') selected @elseif(old('nationality') && old('nationality') == 'belarusian') selected" @endif>Belarusian</option>
                                <option value="belgian" @if(isset($patient) && $patient['nationality'] == 'belgian') selected @elseif(old('nationality') && old('nationality') == 'belgian') selected" @endif>Belgian</option>
                                <option value="belizean" @if(isset($patient) && $patient['nationality'] == 'belizean') selected @elseif(old('nationality') && old('nationality') == 'belizean') selected" @endif>Belizean</option>
                                <option value="beninese" @if(isset($patient) && $patient['nationality'] == 'beninese') selected @elseif(old('nationality') && old('nationality') == 'beninese') selected" @endif>Beninese</option>
                                <option value="bhutanese" @if(isset($patient) && $patient['nationality'] == 'bhutanese') selected @elseif(old('nationality') && old('nationality') == 'bhutanese') selected" @endif>Bhutanese</option>
                                <option value="bolivian" @if(isset($patient) && $patient['nationality'] == 'bolivian') selected @elseif(old('nationality') && old('nationality') == 'bolivian') selected" @endif>Bolivian</option>
                                <option value="bosnian" @if(isset($patient) && $patient['nationality'] == 'bosnian') selected @elseif(old('nationality') && old('nationality') == 'bosnian') selected" @endif>Bosnian</option>
                                <option value="brazilian" @if(isset($patient) && $patient['nationality'] == 'brazilian') selected @elseif(old('nationality') && old('nationality') == 'brazilian') selected" @endif>Brazilian</option>
                                <option value="british" @if(isset($patient) && $patient['nationality'] == 'british') selected @elseif(old('nationality') && old('nationality') == 'british') selected" @endif>British</option>
                                <option value="bruneian" @if(isset($patient) && $patient['nationality'] == 'bruneian') selected @elseif(old('nationality') && old('nationality') == 'bruneian') selected" @endif>Bruneian</option>
                                <option value="bulgarian" @if(isset($patient) && $patient['nationality'] == 'bulgarian') selected @elseif(old('nationality') && old('nationality') == 'bulgarian') selected" @endif>Bulgarian</option>
                                <option value="burkinabe" @if(isset($patient) && $patient['nationality'] == 'burkinabe') selected @elseif(old('nationality') && old('nationality') == 'burkinabe') selected" @endif>Burkinabe</option>
                                <option value="burmese" @if(isset($patient) && $patient['nationality'] == 'burmese') selected @elseif(old('nationality') && old('nationality') == 'burmese') selected" @endif>Burmese</option>
                                <option value="burundian" @if(isset($patient) && $patient['nationality'] == 'burundian') selected @elseif(old('nationality') && old('nationality') == 'burundian') selected" @endif>Burundian</option>
                                <option value="cambodian" @if(isset($patient) && $patient['nationality'] == 'cambodian') selected @elseif(old('nationality') && old('nationality') == 'cambodian') selected" @endif>Cambodian</option>
                                <option value="cameroonian" @if(isset($patient) && $patient['nationality'] == 'cameroonian') selected @elseif(old('nationality') && old('nationality') == 'cameroonian') selected" @endif>Cameroonian</option>
                                <option value="canadian" @if(isset($patient) && $patient['nationality'] == 'canadian') selected @elseif(old('nationality') && old('nationality') == 'canadian') selected" @endif>Canadian</option>
                                <option value="cape verdean" @if(isset($patient) && $patient['nationality'] == 'cape verdean') selected @elseif(old('nationality') && old('nationality') == 'cape verdean') selected" @endif>Cape Verdean</option>
                                <option value="central african" @if(isset($patient) && $patient['nationality'] == 'central african') selected @elseif(old('nationality') && old('nationality') == 'central african') selected" @endif>Central African</option>
                                <option value="chadian" @if(isset($patient) && $patient['nationality'] == 'chadian') selected @elseif(old('nationality') && old('nationality') == 'chadian') selected" @endif>Chadian</option>
                                <option value="chilean" @if(isset($patient) && $patient['nationality'] == 'chilean') selected @elseif(old('nationality') && old('nationality') == 'chilean') selected" @endif>Chilean</option>
                                <option value="chinese" @if(isset($patient) && $patient['nationality'] == 'chinese') selected @elseif(old('nationality') && old('nationality') == 'chinese') selected" @endif>Chinese</option>
                                <option value="colombian" @if(isset($patient) && $patient['nationality'] == 'colombian') selected @elseif(old('nationality') && old('nationality') == 'colombian') selected" @endif>Colombian</option>
                                <option value="comoran" @if(isset($patient) && $patient['nationality'] == 'comoran') selected @elseif(old('nationality') && old('nationality') == 'comoran') selected" @endif>Comoran</option>
                                <option value="congolese" @if(isset($patient) && $patient['nationality'] == 'congolese') selected @elseif(old('nationality') && old('nationality') == 'congolese') selected" @endif>Congolese</option>
                                <option value="costa rican" @if(isset($patient) && $patient['nationality'] == 'costa rican') selected @elseif(old('nationality') && old('nationality') == 'costa rican') selected" @endif>Costa Rican</option>
                                <option value="croatian" @if(isset($patient) && $patient['nationality'] == 'croatian') selected @elseif(old('nationality') && old('nationality') == 'croatian') selected" @endif>Croatian</option>
                                <option value="cuban" @if(isset($patient) && $patient['nationality'] == 'cuban') selected @elseif(old('nationality') && old('nationality') == 'cuban') selected" @endif>Cuban</option>
                                <option value="cypriot" @if(isset($patient) && $patient['nationality'] == 'cypriot') selected @elseif(old('nationality') && old('nationality') == 'cypriot') selected" @endif>Cypriot</option>
                                <option value="czech" @if(isset($patient) && $patient['nationality'] == 'czech') selected @elseif(old('nationality') && old('nationality') == 'czech') selected" @endif>Czech</option>
                                <option value="danish" @if(isset($patient) && $patient['nationality'] == 'danish') selected @elseif(old('nationality') && old('nationality') == 'danish') selected" @endif>Danish</option>
                                <option value="djibouti" @if(isset($patient) && $patient['nationality'] == 'djibouti') selected @elseif(old('nationality') && old('nationality') == 'djibouti') selected" @endif>Djibouti</option>
                                <option value="dominican" @if(isset($patient) && $patient['nationality'] == 'dominican') selected @elseif(old('nationality') && old('nationality') == 'dominican') selected" @endif>Dominican</option>
                                <option value="dutch" @if(isset($patient) && $patient['nationality'] == 'dutch') selected @elseif(old('nationality') && old('nationality') == 'dutch') selected" @endif>Dutch</option>
                                <option value="east timorese" @if(isset($patient) && $patient['nationality'] == 'east timorese') selected @elseif(old('nationality') && old('nationality') == 'east timorese') selected" @endif>East Timorese</option>
                                <option value="ecuadorean" @if(isset($patient) && $patient['nationality'] == 'ecuadorean') selected @elseif(old('nationality') && old('nationality') == 'ecuadorean') selected" @endif>Ecuadorean</option>
                                <option value="egyptian" @if(isset($patient) && $patient['nationality'] == 'egyptian') selected @elseif(old('nationality') && old('nationality') == 'egyptian') selected" @endif>Egyptian</option>
                                <option value="emirian" @if(isset($patient) && $patient['nationality'] == 'emirian') selected @elseif(old('nationality') && old('nationality') == 'emirian') selected" @endif>Emirian</option>
                                <option value="equatorial guinean" @if(isset($patient) && $patient['nationality'] == 'equatorial guinean') selected @elseif(old('nationality') && old('nationality') == 'equatorial guinean') selected" @endif>Equatorial Guinean</option>
                                <option value="eritrean" @if(isset($patient) && $patient['nationality'] == 'eritrean') selected @elseif(old('nationality') && old('nationality') == 'eritrean') selected" @endif>Eritrean</option>
                                <option value="estonian" @if(isset($patient) && $patient['nationality'] == 'estonian') selected @elseif(old('nationality') && old('nationality') == 'estonian') selected" @endif>Estonian</option>
                                <option value="ethiopian" @if(isset($patient) && $patient['nationality'] == 'ethiopian') selected @elseif(old('nationality') && old('nationality') == 'ethiopian') selected" @endif>Ethiopian</option>
                                <option value="fijian" @if(isset($patient) && $patient['nationality'] == 'fijian') selected @elseif(old('nationality') && old('nationality') == 'fijian') selected" @endif>Fijian</option>
                                <option value="filipino" @if(isset($patient) && $patient['nationality'] == 'filipino') selected @elseif(old('nationality') && old('nationality') == 'filipino') selected" @elseif(old('nationality') == null && isset($patient) == false) selected @endif>Filipino</option>
                                <option value="finnish" @if(isset($patient) && $patient['nationality'] == 'finnish') selected @elseif(old('nationality') && old('nationality') == 'finnish') selected" @endif>Finnish</option>
                                <option value="french" @if(isset($patient) && $patient['nationality'] == 'french') selected @elseif(old('nationality') && old('nationality') == 'french') selected" @endif>French</option>
                                <option value="gabonese" @if(isset($patient) && $patient['nationality'] == 'gabonese') selected @elseif(old('nationality') && old('nationality') == 'gabonese') selected" @endif>Gabonese</option>
                                <option value="gambian" @if(isset($patient) && $patient['nationality'] == 'gambian') selected @elseif(old('nationality') && old('nationality') == 'gambian') selected" @endif>Gambian</option>
                                <option value="georgian" @if(isset($patient) && $patient['nationality'] == 'georgian') selected @elseif(old('nationality') && old('nationality') == 'georgian') selected" @endif>Georgian</option>
                                <option value="german" @if(isset($patient) && $patient['nationality'] == 'german') selected @elseif(old('nationality') && old('nationality') == 'german') selected" @endif>German</option>
                                <option value="ghanaian" @if(isset($patient) && $patient['nationality'] == 'ghanaian') selected @elseif(old('nationality') && old('nationality') == 'ghanaian') selected" @endif>Ghanaian</option>
                                <option value="greek" @if(isset($patient) && $patient['nationality'] == 'greek') selected @elseif(old('nationality') && old('nationality') == 'greek') selected" @endif>Greek</option>
                                <option value="grenadian" @if(isset($patient) && $patient['nationality'] == 'grenadian') selected @elseif(old('nationality') && old('nationality') == 'grenadian') selected" @endif>Grenadian</option>
                                <option value="guatemalan" @if(isset($patient) && $patient['nationality'] == 'guatemalan') selected @elseif(old('nationality') && old('nationality') == 'guatemalan') selected" @endif>Guatemalan</option>
                                <option value="guinea-bissauan" @if(isset($patient) && $patient['nationality'] == 'guinea-bissauan') selected @elseif(old('nationality') && old('nationality') == 'guinea-bissauan') selected" @endif>Guinea-Bissauan</option>
                                <option value="guinean" @if(isset($patient) && $patient['nationality'] == 'guinean') selected @elseif(old('nationality') && old('nationality') == 'guinean') selected" @endif>Guinean</option>
                                <option value="guyanese" @if(isset($patient) && $patient['nationality'] == 'guyanese') selected @elseif(old('nationality') && old('nationality') == 'guyanese') selected" @endif>Guyanese</option>
                                <option value="haitian" @if(isset($patient) && $patient['nationality'] == 'haitian') selected @elseif(old('nationality') && old('nationality') == 'haitian') selected" @endif>Haitian</option>
                                <option value="herzegovinian" @if(isset($patient) && $patient['nationality'] == 'herzegovinian') selected @elseif(old('nationality') && old('nationality') == 'herzegovinian') selected" @endif>Herzegovinian</option>
                                <option value="honduran" @if(isset($patient) && $patient['nationality'] == 'honduran') selected @elseif(old('nationality') && old('nationality') == 'honduran') selected" @endif>Honduran</option>
                                <option value="hungarian" @if(isset($patient) && $patient['nationality'] == 'hungarian') selected @elseif(old('nationality') && old('nationality') == 'hungarian') selected" @endif>Hungarian</option>
                                <option value="icelander" @if(isset($patient) && $patient['nationality'] == 'icelander') selected @elseif(old('nationality') && old('nationality') == 'icelander') selected" @endif>Icelander</option>
                                <option value="indian" @if(isset($patient) && $patient['nationality'] == 'indian') selected @elseif(old('nationality') && old('nationality') == 'indian') selected" @endif>Indian</option>
                                <option value="indonesian" @if(isset($patient) && $patient['nationality'] == 'indonesian') selected @elseif(old('nationality') && old('nationality') == 'indonesian') selected" @endif>Indonesian</option>
                                <option value="iranian" @if(isset($patient) && $patient['nationality'] == 'iranian') selected @elseif(old('nationality') && old('nationality') == 'iranian') selected" @endif>Iranian</option>
                                <option value="iraqi" @if(isset($patient) && $patient['nationality'] == 'iraqi') selected @elseif(old('nationality') && old('nationality') == 'iraqi') selected" @endif>Iraqi</option>
                                <option value="irish" @if(isset($patient) && $patient['nationality'] == 'irish') selected @elseif(old('nationality') && old('nationality') == 'irish') selected" @endif>Irish</option>
                                <option value="israeli" @if(isset($patient) && $patient['nationality'] == 'israeli') selected @elseif(old('nationality') && old('nationality') == 'israeli') selected" @endif>Israeli</option>
                                <option value="italian" @if(isset($patient) && $patient['nationality'] == 'italian') selected @elseif(old('nationality') && old('nationality') == 'italian') selected" @endif>Italian</option>
                                <option value="ivorian" @if(isset($patient) && $patient['nationality'] == 'ivorian') selected @elseif(old('nationality') && old('nationality') == 'ivorian') selected" @endif>Ivorian</option>
                                <option value="jamaican" @if(isset($patient) && $patient['nationality'] == 'jamaican') selected @elseif(old('nationality') && old('nationality') == 'jamaican') selected" @endif>Jamaican</option>
                                <option value="japanese" @if(isset($patient) && $patient['nationality'] == 'japanese') selected @elseif(old('nationality') && old('nationality') == 'japanese') selected" @endif>Japanese</option>
                                <option value="jordanian" @if(isset($patient) && $patient['nationality'] == 'jordanian') selected @elseif(old('nationality') && old('nationality') == 'jordanian') selected" @endif>Jordanian</option>
                                <option value="kazakhstani" @if(isset($patient) && $patient['nationality'] == 'kazakhstani') selected @elseif(old('nationality') && old('nationality') == 'kazakhstani') selected" @endif>Kazakhstani</option>
                                <option value="kenyan" @if(isset($patient) && $patient['nationality'] == 'kenyan') selected @elseif(old('nationality') && old('nationality') == 'kenyan') selected" @endif>Kenyan</option>
                                <option value="kittian and nevisian" @if(isset($patient) && $patient['nationality'] == 'kittian and nevisian') selected @elseif(old('nationality') && old('nationality') == 'kittian and nevisian') selected" @endif>Kittian and Nevisian</option>
                                <option value="kuwaiti" @if(isset($patient) && $patient['nationality'] == 'kuwaiti') selected @elseif(old('nationality') && old('nationality') == 'kuwaiti') selected" @endif>Kuwaiti</option>
                                <option value="kyrgyz" @if(isset($patient) && $patient['nationality'] == 'kyrgyz') selected @elseif(old('nationality') && old('nationality') == 'kyrgyz') selected" @endif>Kyrgyz</option>
                                <option value="laotian" @if(isset($patient) && $patient['nationality'] == 'laotian') selected @elseif(old('nationality') && old('nationality') == 'laotian') selected" @endif>Laotian</option>
                                <option value="latvian" @if(isset($patient) && $patient['nationality'] == 'latvian') selected @elseif(old('nationality') && old('nationality') == 'latvian') selected" @endif>Latvian</option>
                                <option value="lebanese" @if(isset($patient) && $patient['nationality'] == 'lebanese') selected @elseif(old('nationality') && old('nationality') == 'lebanese') selected" @endif>Lebanese</option>
                                <option value="liberian" @if(isset($patient) && $patient['nationality'] == 'liberian') selected @elseif(old('nationality') && old('nationality') == 'liberian') selected" @endif>Liberian</option>
                                <option value="libyan" @if(isset($patient) && $patient['nationality'] == 'libyan') selected @elseif(old('nationality') && old('nationality') == 'libyan') selected" @endif>Libyan</option>
                                <option value="liechtensteiner" @if(isset($patient) && $patient['nationality'] == 'liechtensteiner') selected @elseif(old('nationality') && old('nationality') == 'liechtensteiner') selected" @endif>Liechtensteiner</option>
                                <option value="lithuanian" @if(isset($patient) && $patient['nationality'] == 'lithuanian') selected @elseif(old('nationality') && old('nationality') == 'lithuanian') selected" @endif>Lithuanian</option>
                                <option value="luxembourger" @if(isset($patient) && $patient['nationality'] == 'luxembourger') selected @elseif(old('nationality') && old('nationality') == 'luxembourger') selected" @endif>Luxembourger</option>
                                <option value="macedonian" @if(isset($patient) && $patient['nationality'] == 'macedonian') selected @elseif(old('nationality') && old('nationality') == 'macedonian') selected" @endif>Macedonian</option>
                                <option value="malagasy" @if(isset($patient) && $patient['nationality'] == 'malagasy') selected @elseif(old('nationality') && old('nationality') == 'malagasy') selected" @endif>Malagasy</option>
                                <option value="malawian" @if(isset($patient) && $patient['nationality'] == 'malawian') selected @elseif(old('nationality') && old('nationality') == 'malawian') selected" @endif>Malawian</option>
                                <option value="malaysian" @if(isset($patient) && $patient['nationality'] == 'malaysian') selected @elseif(old('nationality') && old('nationality') == 'malaysian') selected" @endif>Malaysian</option>
                                <option value="maldivan" @if(isset($patient) && $patient['nationality'] == 'maldivan') selected @elseif(old('nationality') && old('nationality') == 'maldivan') selected" @endif>Maldivan</option>
                                <option value="malian" @if(isset($patient) && $patient['nationality'] == 'malian') selected @elseif(old('nationality') && old('nationality') == 'malian') selected" @endif>Malian</option>
                                <option value="maltese" @if(isset($patient) && $patient['nationality'] == 'maltese') selected @elseif(old('nationality') && old('nationality') == 'maltese') selected" @endif>Maltese</option>
                                <option value="marshallese" @if(isset($patient) && $patient['nationality'] == 'marshallese') selected @elseif(old('nationality') && old('nationality') == 'marshallese') selected" @endif>Marshallese</option>
                                <option value="mauritanian" @if(isset($patient) && $patient['nationality'] == 'mauritanian') selected @elseif(old('nationality') && old('nationality') == 'mauritanian') selected" @endif>Mauritanian</option>
                                <option value="mauritian" @if(isset($patient) && $patient['nationality'] == 'mauritian') selected @elseif(old('nationality') && old('nationality') == 'mauritian') selected" @endif>Mauritian</option>
                                <option value="mexican" @if(isset($patient) && $patient['nationality'] == 'mexican') selected @elseif(old('nationality') && old('nationality') == 'mexican') selected" @endif>Mexican</option>
                                <option value="micronesian" @if(isset($patient) && $patient['nationality'] == 'micronesian') selected @elseif(old('nationality') && old('nationality') == 'micronesian') selected" @endif>Micronesian</option>
                                <option value="moldovan" @if(isset($patient) && $patient['nationality'] == 'moldovan') selected @elseif(old('nationality') && old('nationality') == 'moldovan') selected" @endif>Moldovan</option>
                                <option value="monacan" @if(isset($patient) && $patient['nationality'] == 'monacan') selected @elseif(old('nationality') && old('nationality') == 'monacan') selected" @endif>Monacan</option>
                                <option value="mongolian" @if(isset($patient) && $patient['nationality'] == 'mongolian') selected @elseif(old('nationality') && old('nationality') == 'mongolian') selected" @endif>Mongolian</option>
                                <option value="moroccan" @if(isset($patient) && $patient['nationality'] == 'moroccan') selected @elseif(old('nationality') && old('nationality') == 'moroccan') selected" @endif>Moroccan</option>
                                <option value="mosotho" @if(isset($patient) && $patient['nationality'] == 'mosotho') selected @elseif(old('nationality') && old('nationality') == 'mosotho') selected" @endif>Mosotho</option>
                                <option value="motswana" @if(isset($patient) && $patient['nationality'] == 'motswana') selected @elseif(old('nationality') && old('nationality') == 'motswana') selected" @endif>Motswana</option>
                                <option value="mozambican" @if(isset($patient) && $patient['nationality'] == 'mozambican') selected @elseif(old('nationality') && old('nationality') == 'mozambican') selected" @endif>Mozambican</option>
                                <option value="namibian" @if(isset($patient) && $patient['nationality'] == 'namibian') selected @elseif(old('nationality') && old('nationality') == 'namibian') selected" @endif>Namibian</option>
                                <option value="nauruan" @if(isset($patient) && $patient['nationality'] == 'nauruan') selected @elseif(old('nationality') && old('nationality') == 'nauruan') selected" @endif>Nauruan</option>
                                <option value="nepalese" @if(isset($patient) && $patient['nationality'] == 'nepalese') selected @elseif(old('nationality') && old('nationality') == 'nepalese') selected" @endif>Nepalese</option>
                                <option value="new zealander" @if(isset($patient) && $patient['nationality'] == 'new zealander') selected @elseif(old('nationality') && old('nationality') == 'new zealander') selected" @endif>New Zealander</option>
                                <option value="ni-vanuatu" @if(isset($patient) && $patient['nationality'] == 'ni-vanuatu') selected @elseif(old('nationality') && old('nationality') == 'ni-vanuatu') selected" @endif>Ni-Vanuatu</option>
                                <option value="nicaraguan" @if(isset($patient) && $patient['nationality'] == 'nicaraguan') selected @elseif(old('nationality') && old('nationality') == 'nicaraguan') selected" @endif>Nicaraguan</option>
                                <option value="nigerien" @if(isset($patient) && $patient['nationality'] == 'nigerien') selected @elseif(old('nationality') && old('nationality') == 'nigerien') selected" @endif>Nigerien</option>
                                <option value="north korean" @if(isset($patient) && $patient['nationality'] == 'north korean') selected @elseif(old('nationality') && old('nationality') == 'north korean') selected" @endif>North Korean</option>
                                <option value="northern irish" @if(isset($patient) && $patient['nationality'] == 'northern irish') selected @elseif(old('nationality') && old('nationality') == 'northern irish') selected" @endif>Northern Irish</option>
                                <option value="norwegian" @if(isset($patient) && $patient['nationality'] == 'norwegian') selected @elseif(old('nationality') && old('nationality') == 'norwegian') selected" @endif>Norwegian</option>
                                <option value="omani" @if(isset($patient) && $patient['nationality'] == 'omani') selected @elseif(old('nationality') && old('nationality') == 'omani') selected" @endif>Omani</option>
                                <option value="pakistani" @if(isset($patient) && $patient['nationality'] == 'pakistani') selected @elseif(old('nationality') && old('nationality') == 'pakistani') selected" @endif>Pakistani</option>
                                <option value="palauan" @if(isset($patient) && $patient['nationality'] == 'palauan') selected @elseif(old('nationality') && old('nationality') == 'palauan') selected" @endif>Palauan</option>
                                <option value="panamanian" @if(isset($patient) && $patient['nationality'] == 'panamanian') selected @elseif(old('nationality') && old('nationality') == 'panamanian') selected" @endif>Panamanian</option>
                                <option value="papua new guinean" @if(isset($patient) && $patient['nationality'] == 'papua new guinea') selected @elseif(old('nationality') && old('nationality') == 'papua new guinea') selected" @endif>Papua New Guinean</option>
                                <option value="paraguayan" @if(isset($patient) && $patient['nationality'] == 'paraguayan') selected @elseif(old('nationality') && old('nationality') == 'paraguayan') selected" @endif>Paraguayan</option>
                                <option value="peruvian" @if(isset($patient) && $patient['nationality'] == 'peruvian') selected @elseif(old('nationality') && old('nationality') == 'peruvian') selected" @endif>Peruvian</option>
                                <option value="polish" @if(isset($patient) && $patient['nationality'] == 'polish') selected @elseif(old('nationality') && old('nationality') == 'polish') selected" @endif>Polish</option>
                                <option value="portuguese" @if(isset($patient) && $patient['nationality'] == 'portuguese') selected @elseif(old('nationality') && old('nationality') == 'portuguese') selected" @endif>Portuguese</option>
                                <option value="qatari" @if(isset($patient) && $patient['nationality'] == 'qatari') selected @elseif(old('nationality') && old('nationality') == 'qatari') selected" @endif>Qatari</option>
                                <option value="romanian" @if(isset($patient) && $patient['nationality'] == 'romanian') selected @elseif(old('nationality') && old('nationality') == 'romanian') selected" @endif>Romanian</option>
                                <option value="russian" @if(isset($patient) && $patient['nationality'] == 'russian') selected @elseif(old('nationality') && old('nationality') == 'russian') selected" @endif>Russian</option>
                                <option value="rwandan" @if(isset($patient) && $patient['nationality'] == 'rwandan') selected @elseif(old('nationality') && old('nationality') == 'rwandan') selected" @endif>Rwandan</option>
                                <option value="saint lucian" @if(isset($patient) && $patient['nationality'] == 'saint lucian') selected @elseif(old('nationality') && old('nationality') == 'saint lucian') selected" @endif>Saint Lucian</option>
                                <option value="salvadoran" @if(isset($patient) && $patient['nationality'] == 'salvadoran') selected @elseif(old('nationality') && old('nationality') == 'salvadoran') selected" @endif>Salvadoran</option>
                                <option value="samoan" @if(isset($patient) && $patient['nationality'] == 'samoan') selected @elseif(old('nationality') && old('nationality') == 'samoan') selected" @endif>Samoan</option>
                                <option value="san marinese" @if(isset($patient) && $patient['nationality'] == 'san marinese') selected @elseif(old('nationality') && old('nationality') == 'san marinese') selected" @endif>San Marinese</option>
                                <option value="sao tomean" @if(isset($patient) && $patient['nationality'] == 'sao tomean') selected @elseif(old('nationality') && old('nationality') == 'sao tomean') selected" @endif>Sao Tomean</option>
                                <option value="saudi" @if(isset($patient) && $patient['nationality'] == 'saudi') selected @elseif(old('nationality') && old('nationality') == 'saudi') selected" @endif>Saudi</option>
                                <option value="scottish" @if(isset($patient) && $patient['nationality'] == 'scottish') selected @elseif(old('nationality') && old('nationality') == 'scottish') selected" @endif>Scottish</option>
                                <option value="senegalese" @if(isset($patient) && $patient['nationality'] == 'senegalese') selected @elseif(old('nationality') && old('nationality') == 'senegalese') selected" @endif>Senegalese</option>
                                <option value="serbian" @if(isset($patient) && $patient['nationality'] == 'serbian') selected @elseif(old('nationality') && old('nationality') == 'serbian') selected" @endif>Serbian</option>
                                <option value="seychellois" @if(isset($patient) && $patient['nationality'] == 'seychellois') selected @elseif(old('nationality') && old('nationality') == 'seychellois') selected" @endif>Seychellois</option>
                                <option value="sierra leonean" @if(isset($patient) && $patient['nationality'] == 'sierra leonean') selected @elseif(old('nationality') && old('nationality') == 'sierra leonean') selected" @endif>Sierra Leonean</option>
                                <option value="singaporean" @if(isset($patient) && $patient['nationality'] == 'singaporean') selected @elseif(old('nationality') && old('nationality') == 'singaporean') selected" @endif>Singaporean</option>
                                <option value="slovakian" @if(isset($patient) && $patient['nationality'] == 'slovakian') selected @elseif(old('nationality') && old('nationality') == 'slovakian') selected" @endif>Slovakian</option>
                                <option value="slovenian" @if(isset($patient) && $patient['nationality'] == 'slovenian') selected @elseif(old('nationality') && old('nationality') == 'slovenian') selected" @endif>Slovenian</option>
                                <option value="solomon islander" @if(isset($patient) && $patient['nationality'] == 'solomon islander') selected @elseif(old('nationality') && old('nationality') == 'solomon islander') selected" @endif>Solomon Islander</option>
                                <option value="somali" @if(isset($patient) && $patient['nationality'] == 'somali') selected @elseif(old('nationality') && old('nationality') == 'somali') selected" @endif>Somali</option>
                                <option value="south african" @if(isset($patient) && $patient['nationality'] == 'south african') selected @elseif(old('nationality') && old('nationality') == 'south african') selected" @endif>South African</option>
                                <option value="south korean" @if(isset($patient) && $patient['nationality'] == 'south korean') selected @elseif(old('nationality') && old('nationality') == 'south korean') selected" @endif>South Korean</option>
                                <option value="spanish" @if(isset($patient) && $patient['nationality'] == 'spanish') selected @elseif(old('nationality') && old('nationality') == 'spanish') selected" @endif>Spanish</option>
                                <option value="sri lankan" @if(isset($patient) && $patient['nationality'] == 'sri lankan') selected @elseif(old('nationality') && old('nationality') == 'sri lankan') selected" @endif>Sri Lankan</option>
                                <option value="sudanese" @if(isset($patient) && $patient['nationality'] == 'sudanese') selected @elseif(old('nationality') && old('nationality') == 'sudanese') selected" @endif>Sudanese</option>
                                <option value="surinamer" @if(isset($patient) && $patient['nationality'] == 'surinamer') selected @elseif(old('nationality') && old('nationality') == 'surinamer') selected" @endif>Surinamer</option>
                                <option value="swazi" @if(isset($patient) && $patient['nationality'] == 'swazi') selected @elseif(old('nationality') && old('nationality') == 'swazi') selected" @endif>Swazi</option>
                                <option value="swedish" @if(isset($patient) && $patient['nationality'] == 'swedish') selected @elseif(old('nationality') && old('nationality') == 'swedish') selected" @endif>Swedish</option>
                                <option value="swiss" @if(isset($patient) && $patient['nationality'] == 'swiss') selected @elseif(old('nationality') && old('nationality') == 'swiss') selected" @endif>Swiss</option>
                                <option value="syrian" @if(isset($patient) && $patient['nationality'] == 'syrian') selected @elseif(old('nationality') && old('nationality') == 'syrian') selected" @endif>Syrian</option>
                                <option value="taiwanese" @if(isset($patient) && $patient['nationality'] == 'taiwanese') selected @elseif(old('nationality') && old('nationality') == 'taiwanese') selected" @endif>Taiwanese</option>
                                <option value="tajik" @if(isset($patient) && $patient['nationality'] == 'tajik') selected @elseif(old('nationality') && old('nationality') == 'tajik') selected" @endif>Tajik</option>
                                <option value="tanzanian" @if(isset($patient) && $patient['nationality'] == 'tanzanian') selected @elseif(old('nationality') && old('nationality') == 'tanzanian') selected" @endif>Tanzanian</option>
                                <option value="thai" @if(isset($patient) && $patient['nationality'] == 'thai') selected @elseif(old('nationality') && old('nationality') == 'thai') selected" @endif>Thai</option>
                                <option value="togolese" @if(isset($patient) && $patient['nationality'] == 'togolese') selected @elseif(old('nationality') && old('nationality') == 'togolese') selected" @endif>Togolese</option>
                                <option value="tongan" @if(isset($patient) && $patient['nationality'] == 'tongan') selected @elseif(old('nationality') && old('nationality') == 'tongan') selected" @endif>Tongan</option>
                                <option value="trinidadian or tobagonian" @if(isset($patient) && $patient['nationality'] == 'trinidadian or tobagonian') selected @elseif(old('nationality') && old('nationality') == 'trinidadian or tobagonian') selected" @endif>Trinidadian or Tobagonian</option>
                                <option value="tunisian" @if(isset($patient) && $patient['nationality'] == 'tunisian') selected @elseif(old('nationality') && old('nationality') == 'tunisian') selected" @endif>Tunisian</option>
                                <option value="turkish" @if(isset($patient) && $patient['nationality'] == 'turkish') selected @elseif(old('nationality') && old('nationality') == 'turkish') selected" @endif>Turkish</option>
                                <option value="tuvaluan" @if(isset($patient) && $patient['nationality'] == 'tuvaluan') selected @elseif(old('nationality') && old('nationality') == 'tuvaluan') selected" @endif>Tuvaluan</option>
                                <option value="ugandan" @if(isset($patient) && $patient['nationality'] == 'ugandan') selected @elseif(old('nationality') && old('nationality') == 'ugandan') selected" @endif>Ugandan</option>
                                <option value="ukrainian" @if(isset($patient) && $patient['nationality'] == 'ukrainian') selected @elseif(old('nationality') && old('nationality') == 'ukrainian') selected" @endif>Ukrainian</option>
                                <option value="uruguayan" @if(isset($patient) && $patient['nationality'] == 'uruguayan') selected @elseif(old('nationality') && old('nationality') == 'uruguayan') selected" @endif>Uruguayan</option>
                                <option value="uzbekistani" @if(isset($patient) && $patient['nationality'] == 'uzbekistani') selected @elseif(old('nationality') && old('nationality') == 'uzbekistani') selected" @endif>Uzbekistani</option>
                                <option value="venezuelan" @if(isset($patient) && $patient['nationality'] == 'venezuelan') selected @elseif(old('nationality') && old('nationality') == 'venezuelan') selected" @endif>Venezuelan</option>
                                <option value="vietnamese" @if(isset($patient) && $patient['nationality'] == 'vietnamese') selected @elseif(old('nationality') && old('nationality') == 'vietnamese') selected" @endif>Vietnamese</option>
                                <option value="welsh" @if(isset($patient) && $patient['nationality'] == 'welsh') selected @elseif(old('nationality') && old('nationality') == 'welsh') selected" @endif>Welsh</option>
                                <option value="yemenite" @if(isset($patient) && $patient['nationality'] == 'yemenite') selected @elseif(old('nationality') && old('nationality') == 'yemenite') selected" @endif>Yemenite</option>
                                <option value="zambian" @if(isset($patient) && $patient['nationality'] == 'zambian') selected @elseif(old('nationality') && old('nationality') == 'zambian') selected" @endif>Zambian</option>
                                <option value="zimbabwean" @if(isset($patient) && $patient['nationality'] == 'zimbabwean') selected @elseif(old('nationality') && old('nationality') == 'zimbabwean') selected" @endif>Zimbabwean</option>
                            </select>
                        </div>
                    </div>
                </div>
                <div class="col-lg-6">
                    <div class="form-group">
                        <div class="input-group mb-3">
                            <div class="input-group-prepend">
                            <span class="input-group-text" id="basic-addon1">
                                <i class="fa fa-user"></i>
                            </span>
                            </div>
                            <input type="text" class="form-control" placeholder="{{__('Mother\'s Name')}}" name="mother_name" id="mother_name" @if(isset($patient)) value="{{$patient->mother_name}}" @elseif(old('mother_name')) value="{{old('mother_name')}}" @endif readonly>
                        </div>
                    </div>
                </div>

                <div class="col-lg-6">
                    <div class="form-group">
                        <div class="input-group mb-3">
                            <div class="input-group-prepend">
                            <span class="input-group-text" id="basic-addon1">
                                <i class="fa fa-user"></i>
                            </span>
                            </div>
                            <input type="text" class="form-control" placeholder="{{__('Guardian\'s Name')}}" name="guardian_name" id="guardian_name" @if(isset($patient)) value="{{$patient->guardian_name}}" @elseif(old('guardian_name')) value="{{old('guardian_name')}}" @endif readonly>
                        </div>
                    </div>
                </div>
                <div class="col-lg-12">
                    <div class="form-group">
                        <div class="input-group mb-3">
                            <div class="input-group-prepend">
                            <span class="input-group-text" id="basic-addon1">
                                <i class="fas fa-envelope"></i>
                            </span>
                            </div>
                            <input type="email" class="form-control" placeholder="{{__('Email Address')}}" name="email" id="email" @if(isset($patient)) value="{{$patient->email}}" @elseif(old('email')) value="{{old('email')}}" @endif>
                        </div>
                    </div>
                </div>
    
                <div class="col-sm-12 mt-2 increments_contact">
                    <label>Contact Number</label>
                    <div class="input-group control-group">
                        <div class="custom-file mr-2">
                            <div class="input-group-prepend">
                                <span class="input-group-text" id="basic-addon1">
                                    <strong>+63</strong>
                                </span>
                            </div>
                            <input type="number" maxlength="10"  class="form-control" placeholder="{{__('Contact Number')}}" name="phone[]" id="phone">

                        </div>
                        
                        <button type="button" class="btn btn-success add_contact_row"  >
                            <i class="fa fa-plus"></i>
                        </button>
                    </div>
                </div>

                <div class="row ml-1">
                    <ul class="p-0 m-0">
                        @if (isset($patient->phones))
                            @foreach ($patient->phones as $phone)
                                <li class="d-flex align-items-center my-2 p-2">
                                    <div class="flex-shrink-1 mr-2" >
                                        <input type="text" class="form-control" placeholder="{{ __('Phone Number') }}" name="street" id="street" value="{{ $phone->phone }}" readonly >
                                    </div>
                                    
                                    <div class="flex-shrink-1">
                                        {{-- @php
                                        dd($phone['id']);

                                        @endphp --}}
                                        <button type="button" phone_id="{{ $phone['id'] }}" class="btn btn-danger btn-sm delete_contacts" >
                                            Delete
                                        </button>
                                    </div> 
                                    
                            @endforeach
                        @endif
                    </ul>
                </div>
            </div>
            <div class="row">
                <div class="col-lg-12">
                    
                    <div class="card">
                        <div class="card-header">
                            <h5 class="card-title"> {{__('Address')}}</h5>
                        </div>
    
                        <div class="card-body m-0 p-0">
                            <div class="row m-2">
                                <div class="col-lg-12">
                                    <div class="form-group">
                                        <div class="input-group mb-3">
                                            <div class="input-group-prepend">
                                                <span class="input-group-text" id="basic-addon1">
                                                    <i class="fas">Unit No./Street</i>
                                                </span>
                                            </div>
                                            <input type="text" class="form-control" placeholder="{{ __('Unit No./Street') }}" name="street" id="street" @if (isset($patient)) value="{{ $patient->street }}" @elseif(old('street')) value="{{ old('street') }}" @endif>
                                        </div>
                                    </div>
                                </div>
    
                                <div class="col-lg-6">
                                    <div class="form-group">
                                        <div class="input-group mb-3">
                                            <div class="input-group-prepend">
                                                <span class="input-group-text" id="basic-addon1">
                                                    <i class="fas">Barangay</i>
                                                </span>
                                            </div>
                                            <input type="text" class="form-control" placeholder="{{ __('Barangay') }}" name="barangay" id="barangay" @if (isset($patient)) value="{{ $patient->barangay }}" @elseif(old('baranga')) value="{{ old('barangay') }}" @endif>
                                        </div>
                                    </div>
                                </div>
    
                                <div class="col-lg-6">
                                    <div class="form-group">
                                        <div class="input-group mb-3">
                                            <div class="input-group-prepend">
                                                <span class="input-group-text" id="basic-addon1">
                                                    <i class="fas">City/Municipality</i>
                                                </span>
                                            </div>
                                            <input type="text" class="form-control" placeholder="{{ __('City/Municipality') }}" name="city" id="city" @if (isset($patient)) value="{{ $patient->city }}" @elseif(old('city')) value="{{ old('city') }}" @endif>
                                            <!-- <select class="form-control" name="city" id="city"></select> -->
                                        </div>
                                    </div>
                                </div>
    
                                <div class="col-lg-6">
                                    <div class="form-group">
                                        <div class="input-group mb-3">
                                            <div class="input-group-prepend">
                                                <span class="input-group-text" id="basic-addon1">
                                                    <i class="fas">Province</i>
                                                </span>
                                            </div>
                                            <input type="text" class="form-control" placeholder="{{ __('Province') }}" name="province" id="province" @if (isset($patient)) value="{{ $patient->province }}" @elseif(old('province')) value="{{ old('province') }}" @endif>
                                        </div>
                                    </div>
                                </div>
    
                                <div class="col-lg-6">
                                    <div class="form-group">
                                        <div class="input-group mb-4">
                                            <div class="input-group-prepend">
                                                <span class="input-group-text" id="basic-addon1">
                                                    <i class="fas">Region</i>
                                                </span>
                                            </div>
                                            <select class="form-control" name="region" id="region_name">
                                                @if (isset($patient))
                                                    @foreach ($regions as $region)
                                                        <option value="{{ $region['id'] }}" @if(isset($patient) && $patient['region'] == $region['id']) selected @endif>{{ $region['name'] }}</option>
                                                    @endforeach
                                                @endif
                                            </select>
                                        </div>
                                    </div>
                                </div>
    
                                <div class="col-lg-6">
                                    <div class="form-group">
                                        <div class="input-group mb-3">
                                            <div class="input-group-prepend">
                                                <span class="input-group-text" id="basic-addon1">
                                                    <i class="fas">Country</i>
                                                </span>
                                            </div>
                                            <input type="text" class="form-control" placeholder="{{ __('Country') }}" name="country" id="country" @if (isset($patient)) value="{{ $patient->country }}" @elseif(old('country')) value="{{ old('country') }}"@else value="Philippines" @endif readonly>
                                        </div>
                                    </div>
                                </div>
    
                                <div class="col-lg-6">
                                    <div class="form-group">
                                        <div class="input-group mb-3">
                                            <div class="input-group-prepend">
                                                <span class="input-group-text" id="basic-addon1">
                                                    <i class="fas fa-globe"></i>
                                                </span>
                                            </div>
                                            <input type="text" class="form-control" placeholder="{{ __('Zip Code') }}" name="zip_code" id="zip_code" @if (isset($patient)) value="{{ $patient->zip_code }}" @elseif(old('zip_code')) value="{{ old('zip_code') }}" @endif>
                                        </div>
                                    </div>
                                </div>
                            </div>
                        </div>
                    </div>
                </div>
            </div>
    
        </div>

        
    
    </div>
    
    

    </div>
    <!-- /.card-body -->
    <div class="card-footer">
      <button type="submit" class="btn btn-primary">
        <i class="fa fa-check"></i> {{__('Save')}}
      </button>
    </div>
  </form>

</div>

@endsection
@section('scripts')
  <script src="{{url('js/patient/profile.js')}}"></script>
@endsection


{{-- <div class="col-lg-4">
                    <div class="form-group">
                        <div class="form-group">
                            <div class="input-group mb-3">
                                <div class="input-group-prepend">
                                <span class="input-group-text" id="basic-addon1">
                                    <i class="fas fa-globe"></i>
                                </span>
                                </div>
                                <select class="form-control" name="country_id" id="country_id">
                                    <option value="" disabled selected>{{__('Select nationality')}}</option>
                                    @if(isset($patient)&&isset($patient['country']))
                                        <option value="{{$patient['country_id']}}" selected>{{$patient['country']['nationality']}}</option>
                                    @endif
                                </select>
                            </div>
                        </div>
                    </div>
                </div> --}}
    
                {{-- <div class="col-lg-4">
                    <div class="form-group">
                    <div class="input-group mb-3">
                        <div class="input-group-prepend">
                        <span class="input-group-text" id="basic-addon1">
                            <i class="fa fa-id-card"></i>
                        </span>
                        </div>
                        <input type="text" class="form-control" placeholder="{{__('National ID')}}" name="national_id" id="national_id" @if(isset($patient)) value="{{$patient->national_id}}" @elseif(old('national_id')) value="{{old('national_id')}}" @endif>
                    </div>
                    </div>
                </div> --}}
                {{-- <div class="col-lg-4">
                    <div class="form-group">
                    <div class="input-group mb-3">
                        <div class="input-group-prepend">
                        <span class="input-group-text" id="basic-addon1">
                            <i class="fa fa-passport"></i>
                        </span>
                        </div>
                        <input type="text" class="form-control" placeholder="{{__('Passport no')}}" name="passport_no" id="passport_no" @if(isset($patient)) value="{{$patient->passport_no}}" @elseif(old('passport_no')) value="{{old('passport_no')}}" @endif>
                    </div>
                    </div>
                </div> --}}
                {{-- <div class="col-lg-4">
                    <div class="form-group">
                        <div class="form-group">
                            <div class="input-group mb-3">
                                <div class="input-group-prepend">
                                <span class="input-group-text" id="basic-addon1">
                                    <i class="fas fa-mars"></i>
                                </span>
                                </div>
                                <select class="form-control" name="gender" placeholder="{{__('Gender')}}" id="gender" required>
                                    <option value="" disabled selected>{{__('Select Gender')}}</option>
                                    <option value="male"  @if(isset($patient)&&$patient['gender']=='male') selected @elseif(old('gender')=='male') selected  @endif>{{__('Male')}}</option>
                                    <option value="female"  @if(isset($patient)&&$patient['gender']=='female') selected @elseif(old('gender')=='female') selected @endif>{{__('Female')}}</option>
                                </select>
                            </div>
                        </div>
                    </div>
                </div>
    
                <div class="col-lg-4">
                    <div class="form-group">
                        <div class="form-group">
                            <div class="input-group mb-3">
                                <div class="input-group-prepend">
                                <span class="input-group-text" id="basic-addon1">
                                    <i class="fas fa-baby"></i>
                                </span>
                                </div>
                                <input type="text" class="form-control datepicker" placeholder="{{__('Date of birth')}}" name="dob" id="dob" required @if(isset($patient)) value="{{$patient['dob']}}" @elseif(old('dob')) value="{{old('dob')}}" @endif readonly>
                            </div>
                        </div>
                    </div>
                </div>
    
                <div class="col-lg-4">
                    <div class="row">
                        <div class="col-lg-6 col-sm-6 col-xs-6 col-md-6 pr-0">
                            <div class="input-group mb-3">
                                <div class="input-group-prepend">
                                    <span class="input-group-text" id="basic-addon1">
                                    <i class="fas fa-baby"></i>
                                    </span>
                                </div>
                                <input type="number" class="form-control" name="age" id="age" placeholder="{{__('Age')}}" @if(!isset($patient)&&old('age')) value="{{old('age')}}" @endif required>
                            </div>
                        </div>
                        <div class="col-lg-6 col-sm-6 col-xs-6 col-md-6 pl-0">
                            <div class="input-group mb-3">
                                <select class="form-control" name="age_unit" id="age_unit" required>
                                    <option value="" disabled selected>{{__('Select age unit')}}</option>
                                    <option value="years" @if(!isset($patient)&&old('age_unit')=='years') selected @endif>{{__('Years')}}</option>
                                    <option value="months" @if(!isset($patient)&&old('age_unit')=='months') selected @endif>{{__('Months')}}</option>
                                    <option value="days" @if(!isset($patient)&&old('age_unit')=='days') selected @endif>{{__('Days')}}</option>
                                </select>
                            </div>
                        </div>
                    </div>
                    
                </div> --}}
                {{-- <div class="col-lg-4">
                    <div class="form-group">
                        <div class="form-group">
                            <div class="input-group mb-3">
                                <div class="input-group-prepend">
                                <span class="input-group-text" id="basic-addon1">
                                    <i class="fas fa-map-marker-alt"></i>
                                </span>
                                </div>
                                <input type="text" class="form-control" placeholder="{{__('Address')}}" name="address" id="address" @if(isset($patient)) value="{{$patient->address}}" @elseif(old('address')) value="{{old('address')}}" @endif>
                            </div>
                        </div>
                    </div>
                </div> --}}