@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="5-1">
      <div class="multiple-form dashboard-radio">
         <h4>Alternate health care proxy</h4>
         <p>Alternative proxy's information</p>
         <div class="form">
            <p class="sub-title">Alternative Representative</p>

              <div class="form-group mb-3">
               <label for="name">Name</label>
               <input type="text" name="alternative_name" id="alternative_name" value="{{ isset($alternate_proxy['alternative_name']) ? $alternate_proxy['alternative_name'] : '' }}"  >
               </div>
               <div class="row">
                  <div class="col-md-6">
                     <div class="form-group mb-3">
                     <label for="street">Street Address</label>
                     <input type="text" name="alternative_street" id="alternative_street"  value="{{ isset($alternate_proxy['alternative_street']) ? $alternate_proxy['alternative_street'] : '' }}" >
                     </div>
                  </div>

                  <div class="col-md-6">
                     <div class="form-group mb-3">
                     <label for="city">Country</label>
                     {{-- <input type="text" name="alternative_town" id="alternative_town"  value="{{ isset($alternate_proxy['alternative_town']) ? $alternate_proxy['alternative_town'] : '' }}" > --}}
                     <input type="hidden" name="country_value" id="country_value" value="{{ isset($alternate_proxy['alternative_country']) ? $alternate_proxy['alternative_country'] : '' }}"/>
                     <input type="hidden" id="country_code_value">
                     <select id="country_dropdown_a" name="alternative_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="state">State</label>
                     {{-- <input type="text" name="alternative_state" id="alternative_state"  value="{{ isset($alternate_proxy['alternative_state']) ? $alternate_proxy['alternative_state'] : '' }}" > --}}
                     <input type="hidden" name="state_value" id="state_value"  value="{{ isset($alternate_proxy['alternative_state']) ? $alternate_proxy['alternative_state'] : '' }}"/>
                     <select id="state_dropdown_a" name="alternative_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="alternative_zip_code" id="alternative_zip_code"  value="{{ isset($alternate_proxy['alternative_zip_code']) ? $alternate_proxy['alternative_zip_code'] : '' }}" maxlength="5" data-zipcode-input maxlength="5" data-message-element="zipcode_message" data-userdefined-country-code="userdefinedCountryCode" data-state-dropdown="state_dropdown_a" data-country-dropdown="country_dropdown_a">
                     <span class="invalid-zipcode invalid-feedback d-block text-danger" id="zipcode_message" role="alert"></span>
                     </div>
                  </div>
                  <div class="col-md-6">
                     <div class="form-group mb-3">
                     <label for="zip_code">Phone</label>
                     <input type="text" name="alternative_phone" id="alternative_phone" value="{{ isset($alternate_proxy['alternative_phone']) ? $alternate_proxy['alternative_phone'] : '' }}" >
                     <small>e.g. 0123456789</small>
                     </div>
                  </div>
                  <div class="col-md-6">
                     <div class="form-group mb-3">
                     <label for="zip_code">Relationship</label>
                     <input type="text" name="alternative_relationship" id="alternative_relationship"  value="{{ isset($alternate_proxy['alternative_relationship']) ? $alternate_proxy['alternative_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.five') }}'">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">
      <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> -->
@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('v2/js/form-validation.js') }}?v={{ time() }}"></script>
<script src="{{ url('fetch_complete_address_by_zipcode.js') }}"></script>

@endsection