@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="5-1">
      <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">Alternate Health Care Proxy</div>
                    <div class="card-sub-title">Alternative Proxy's Information</div>
          
                     <div class="card" id="child">
                       <div class="card-sub-title">Alternative Representative</div>
                       <div class="card-body">
                           <div class="form-group mb-3">
                           <label for="name">Name</label>
                           <input type="text" class="form-control modified-input" name="alternative_name" id="alternative_name" value="{{ isset($alternate_proxy['alternative_name']) ? $alternate_proxy['alternative_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="alternative_street" id="alternative_street" placeholder="Street Address" value="{{ isset($alternate_proxy['alternative_street']) ? $alternate_proxy['alternative_street'] : '' }}">
                           </div>
 
                           <div class="form-group mb-3">
                           <label for="state">State</label>
                           <input type="text" class="form-control modified-input" name="alternative_state" id="alternative_state" placeholder="State" value="{{ isset($alternate_proxy['alternative_state']) ? $alternate_proxy['alternative_state'] : '' }}">
                           </div>
 
                           <div class="form-group mb-3">
                           <label for="city">City/Town</label>
                           <input type="text" class="form-control modified-input" name="alternative_town" id="alternative_town" placeholder="City/Town" value="{{ isset($alternate_proxy['alternative_town']) ? $alternate_proxy['alternative_town'] : '' }}">
                           </div>
 
                           <div class="form-group mb-3">
                             <label for="zip_code">ZIP Code</label>
                             <input type="text" class="form-control modified-input" name="alternative_zip_code" id="alternative_zip_code" placeholder="ZIP Code" value="{{ isset($alternate_proxy['alternative_zip_code']) ? $alternate_proxy['alternative_zip_code'] : '' }}">
                           </div>
 
                           <div class="form-group mb-3">
                             <label for="zip_code">Phone</label>
                             <input type="text" class="form-control modified-input" name="alternative_phone" id="alternative_phone" placeholder="Phone" value="{{ isset($alternate_proxy['alternative_phone']) ? $alternate_proxy['alternative_phone'] : '' }}">
                             <small id="cityHelp" class="form-text text-muted">e.g. 0123456789</small>
                           </div>
 
                           <div class="form-group mb-3">
                             <label for="zip_code">Relationship</label>
                             <input type="text" class="form-control modified-input" name="alternative_relationship" id="alternative_relationship" placeholder="relationship" value="{{ isset($alternate_proxy['alternative_relationship']) ? $alternate_proxy['alternative_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>Who can complete a Living Will?</p>
                           <span class="tooltiptext">Anyone over 18 years old with a sound mind can create a Living Will.</span>
                        </div>
                        <div class="tooltip">
                           <p>How do I change my State?</p>
                           <span class="tooltiptext">The questionnaire is customized based on the State you live in. To change your resident State, visit the "Location" step in the progress bar above.</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.five') }}'" 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