@extends('layouts.v2.frontend-user-backend')

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

@section('content')
@include('frontend.forms.v2.Living-Will.stepIndicator')
 <!-- start -->
<div class="container">
    <form action="{{route('LivingWillFormStore')}}" method="POST" id="signUpForm" class="multiple-form">
      @csrf
      <input type="hidden" id="stepInput" name="step" value="5">

      <div class="multiple-form dashboard-radio">
         <h4>If I need someone to speak for me</h4>
         <p>First choice for Health Care Proxy</p>
         <div class="form">
            <div class="form-group mb-3">
            <label for="name">Name</label>
            <input type="text"  name="proxy_name" value="{{ isset($proxy['proxy_name']) ? $proxy['proxy_name'] : '' }}" id="proxy_name"  >
            </div>

            <div class="form-group mb-3">
            <label for="street">Street Address</label>
            <input type="text"  name="proxy_street" value="{{ isset($proxy['proxy_street']) ? $proxy['proxy_street'] : '' }}" id="proxy_street"  >
            </div>
            
            <div class="row">
               <div class="col-md-6">
                  <div class="form-group mb-3">
                  <label for="state">Country</label>
                  {{-- <input type="text"  name="proxy_state" value="{{ isset($proxy['proxy_state']) ? $proxy['proxy_state'] : '' }}" id="proxy_state"  > --}}
                  <input type="hidden" name="country_value" id="country_value" value="{{ isset($proxy['proxy_country']) ? $proxy['proxy_country'] : '' }}"/>
                  <input type="hidden" id="country_code_value">
                  <select id="country_dropdown_a" name="proxy_country" class="form-control" data-country-dropdown data-country-value="country_value" data-state-dropdown="state_dropdown_a" data-state-value="state_value" data-userdefined-country-code="country_code_value">
                     <option value="">Select Country</option>
                  </select>

                  </div>
               </div>
               <div class="col-md-6">
                  <div class="form-group mb-3">
                  <label for="city">State</label>
                  {{-- <input type="text"  name="proxy_town" value="{{ isset($proxy['proxy_state']) ? $proxy['proxy_state'] : '' }}" id="proxy_town"  > --}}
                  <input type="hidden" name="state_value" id="state_value"  value="{{ isset($proxy['proxy_state']) ? $proxy['proxy_state'] : '' }}"/>
                  <select id="state_dropdown_a" name="proxy_state" class="form-control" data-state-dropdown>
                     <option value="">Select State</option>
                  </select>
               </div>
               </div>
            
               <div class="col-md-6">
                  <div class="form-group mb-3">
                  <input type="hidden" id="userdefinedCountryCode" value="US" />
                  <label for="zip_code">ZIP Code</label>
                  <input type="text"  name="proxy_zip_code" value="{{ isset($proxy['proxy_zip_code']) ? $proxy['proxy_zip_code'] : '' }}" id="proxy_zip_code" maxlength="5" data-zipcode-input maxlength="5" data-message-element="zipcode_message" data-userdefined-country-code="userdefinedCountryCode" data-state-dropdown="state_dropdown_a" data-country-dropdown="country_dropdown_a">
                  <span class="invalid-zipcode invalid-feedback d-block text-danger" id="zipcode_message" role="alert"></span>
                  </div>
               </div>

               <div class="col-md-6">
                  <div class="form-group mb-3">
                  <label for="zip_code">Relationship</label>
                  <input type="text"  name="proxy_relationship" value="{{ isset($proxy['proxy_relationship']) ? $proxy['proxy_relationship'] : '' }}" id="proxy_relationship"  >
                  <small>e.g. brother, wife, friend, etc</small>
                  </div>
               </div>
               
            </div>
         </div>
      </div>


      <!-- start previous / next buttons -->
      <div class="submit-button-multiple">
            <button type="button" onclick="window.location.href = '{{ route('livingwill.create.step.four') }}'">Back</button>
            <button type="submit" class="submit-btn">Save and Continue</button>
            <button type="submit" name="preview_submit" class="d-none" value="preview">{{env('PREVIEW_BUTTON_TEXT')}}</button>
         <button type="button" class="skip-btn d-none">Skip Step</button>
      </div>
      <!-- end previous / next buttons -->
    </form>

      <div class="faq-box d-none">
         <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>


@endsection
@section('page-js')
<script src="{{ url('frontend/assets/js/forms/living-will-multi-step.js') }}?v={{ time() }}"></script>
<script src="{{ url('frontend/assets/js/forms/custom.js?v=10.3') }}"></script>
<script src="{{ url('fetch_complete_address_by_zipcode.js') }}"></script>
<script src="{{ url('v2/js/form-validation.js') }}?v={{ time() }}"></script>

@endsection