@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="5-3">
      <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">Instructions for Health Care Proxy</div>
                   <div class="card-sub-title">I want your health care proxy to be able to:</div>
                   <div class="form-check mb-3">
                     @if( isset($livingWillForm->proxy_authority) &&  $livingWillForm->proxy_authority == "Limited to following the directions listed in this document")
                     <div class="form-group mb-3">
                        <label class="form-check-label">
                           <input type="checkbox" class="form-check-input" name="tube_feeding" value="yes" {{ isset($livingWillForm->tube_feeding) &&  $livingWillForm->tube_feeding == "yes" ? 'checked' : ''}}>
                           <p>Decide if I need tube feeding</p>
                        </label>
                     </div>
                     @endif
                     <div class="form-group mb-3">
                        <label class="form-check-label">
                           <input type="checkbox" class="form-check-input" name="medical_records" value="yes" {{ isset($livingWillForm->medical_records) &&  $livingWillForm->medical_records == "yes" ? 'checked' : ''}}>
                           <p>Have access to my medical records</p>
                        </label>
                     </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> 
                  </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_2') }}'" 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