@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="5-3">
      <div class="multiple-form dashboard-radio">
         <h4>Instructions for health care proxy</h4>
         <p>I want your health care proxy to be able to:</p>
         <div class="form">
            <div class="row">
               @if( isset($livingWillForm->proxy_authority) &&  $livingWillForm->proxy_authority == "Limited to following the directions listed in this document")
               <div class="col-12">
                  <div class="list-form-area-multiple">
                     <div class="flex-box10">
                        <label for="">Decide if I need tube feeding</label>
                     </div>
                     <div class="checkbox-item">
                        <input type="checkbox" name="tube_feeding" value="yes" {{ isset($livingWillForm->tube_feeding) &&  $livingWillForm->tube_feeding == "yes" ? 'checked' : ''}}>
                     </div> 
                  </div>
               </div>
               <div class="tube_feeding_error text-danger small fw-bold mt-2" ></div>
               @endif
               <div class="col-12">
                  <div class="list-form-area-multiple">
                     <div class="flex-box10">
                        <label for="">Have access to my medical records</label>
                     </div>
                     <div class="checkbox-item">
                        <input type="checkbox" name="medical_records" value="yes" {{ isset($livingWillForm->medical_records) &&  $livingWillForm->medical_records == "yes" ? 'checked' : ''}}>
                     </div> 
                  </div>
               </div>
               <div class="medical_records_error text-danger small fw-bold mt-2" ></div>
            </div>

            <!-- start previous / next buttons -->
               <div class="submit-button-multiple">
                  <button type="button" onclick="window.location.href = '{{ route('livingwill.create.step.five_2') }}'">Back</button>
                  <button type="submit" class="submit-btn">Save and Continue</button>
                  <button type="submit" class="d-none"  name="preview_submit" value="preview">{{env('PREVIEW_BUTTON_TEXT')}}</button>
                  <button type="button" class="skip-btn d-none">Skip Step</button>
               </div>
            <!-- end previous / next buttons -->
         </div>
      </div>
    </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> 

@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>
@endsection