@extends('layouts.frontend')

@section('title', '| Free Living Will')

@section('content')
@include('frontend.forms.Living-Will.stepIndicator')
 <!-- start -->
<div class="container">
    <form action="{{route('LivingWillFormStore')}}" method="POST" id="signUpForm">
      @csrf
      <input type="hidden" id="stepInput" name="step" value="5">
      <div class="card">
         <div class="card-body">
            <!-- step 1 -->
            <div class="step" style="display: block">
               <div class="row">
                 <div class="col-md-10 col-lg-8 order-1 order-md-1 order-lg-1">
                    <div class="card-title">If I need someone to speak for me</div>
                    <div class="card-sub-title">First choice for Health Care Proxy</div>
          
                     <div class="card" id="child">
                       <div class="card-body">
                           <div class="form-group mb-3">
                           <label for="name">Name</label>
                           <input type="text" class="form-control modified-input" name="proxy_name" value="{{ isset($proxy['proxy_name']) ? $proxy['proxy_name'] : '' }}" id="proxy_name" placeholder="Full Name">
                           </div>
 
                           <div class="form-group mb-3">
                           <label for="street">Street Address</label>
                           <input type="text" class="form-control modified-input" name="proxy_street" value="{{ isset($proxy['proxy_street']) ? $proxy['proxy_street'] : '' }}" id="proxy_street" placeholder="Street Address">
                           </div>
 
                           <div class="form-group mb-3">
                           <label for="state">State</label>
                           <input type="text" class="form-control modified-input" name="proxy_state" value="{{ isset($proxy['proxy_state']) ? $proxy['proxy_state'] : '' }}" id="proxy_state" placeholder="State">
                           </div>
 
                           <div class="form-group mb-3">
                           <label for="city">City/Town</label>
                           <input type="text" class="form-control modified-input" name="proxy_town" value="{{ isset($proxy['proxy_town']) ? $proxy['proxy_town'] : '' }}" id="proxy_town" placeholder="City/Town">
                           </div>
 
                           <div class="form-group mb-3">
                             <label for="zip_code">ZIP Code</label>
                             <input type="text" class="form-control modified-input" name="proxy_zip_code" value="{{ isset($proxy['proxy_zip_code']) ? $proxy['proxy_zip_code'] : '' }}" id="proxy_zip_code" placeholder="ZIP Code">
                           </div>
                           <div class="form-group mb-3">
                             <label for="zip_code">Relationship</label>
                             <input type="text" class="form-control modified-input" name="proxy_relationship" value="{{ isset($proxy['proxy_relationship']) ? $proxy['proxy_relationship'] : '' }}" id="proxy_relationship" placeholder="relationship">
                             <small id="cityHelp" class="form-text text-muted">e.g. brother, wife, friend, etc</small>
                           </div>
                       </div>
                     </div>
                 </div>
                  <div class="col-md-8 col-lg-4 order-3 order-md-3 order-lg-2">
                     <div class="faq-box">
                        <div class="title">Frequently Asked Questions</div>
                        <div class="tooltip">
                           <p>What is a Healthcare proxy?</p>
                           <span class="tooltiptext">A Healthcare proxy is a legal document that allows you to appoint someone as your healthcare agent or proxy. This person is authorized to make medical decisions if they cannot do so due to incapacitation.</span>
                        </div>
                        <div class="tooltip">
                           <p>Who can be a Healthcare proxy?</p>
                           <span class="tooltiptext">In most cases, a Healthcare proxy can be any trusted individual willing to act on your behalf. This person should be someone who understands your healthcare preferences and is capable of making informed decisions as per your wishes.</span>
                        </div>
                     </div>
                  </div>
                  <!-- start previous / next buttons -->
                  <div class="col-md-12 order-2 order-md-2 order-lg-3">
                     <div id="buttonsection">
                        <div class="form-footer d-flex justify-content-between">
                           <div>
                           <button type="button" onclick="window.location.href = '{{ route('livingwill.create.step.four') }}'" class="btn btn-light btn-lg back-btn">Back</button>
                           <button type="submit" class="btn btn-light btn-lg">Save and Continue</button>
                        </div>
                        <button type="submit" class="btn btn-light btn-lg" name="preview_submit" value="preview">{{env('PREVIEW_BUTTON_TEXT')}}</button>
                           <button type="button" class="btn btn-light btn-lg skip-btn d-none">Skip Step</button>
                        </div>
                     </div>
                  </div>
                  <!-- end previous / next buttons -->
              </div>
            </div>
         </div>
      </div>
</div>

@endsection
@section('page-js')
<script src="{{ url('frontend/assets/js/forms/living-will-multi-step.js?v=10.1') }}"></script>
<script src="{{ url('frontend/assets/js/forms/custom.js?v=10.3') }}"></script>

@endsection