@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="6">
      <div class="multiple-form dashboard-radio">
         <h4>Contact list</h4>
         <p>Do you want to provide a list of people for your doctor to contact before any vital treatment is stopped?</p>
         <div class="form">
            <div class="dashboard-radio-form"> 
               <div class="form-check">
                  <input id="vitaltreatment-y" class="form-check-input" name="contact_status" type="radio" value="yes"
                  {{ isset($livingWillForm->contact_status) &&  $livingWillForm->contact_status == "yes" ? 'checked' : ''}}>
                  <label for="vitaltreatment-y"><p>Yes</p></label>
               </div>
               <div class="form-check">
                  <input id="vitaltreatment-n" class="form-check-input" name="contact_status" type="radio" value="no"
                  {{ isset($livingWillForm->contact_status) &&  $livingWillForm->contact_status == "no" ? 'checked' : ''}}>
                  <label for="vitaltreatment-n"><p>No</p></label>
               </div>

            </div>

            <div id="contact-container_holder" class="child-card-holder">
               <div id="contact-container" class="mb-2">
                  @if(empty($livingWillForm->contacts))
                        
                           <div class="card list mb-3" id="child">
                              <div class="card-header">
                                    <div class="card-title">Contact</div>
                                    <a class="r-button" onclick="removetList(this)">
                                       <span class="fas fa-times"></span>
                                       <span class="remove">Remove</span>
                                    </a>
                                 </div>
                                 <div class="card-body">
                                    <div class="row">
                                       <div class="col-md-6">
                                          <div class="form-group mb-3">
                                             <label for="name">Name</label>
                                             <input type="text" name="contact_name[]" id="contact_name" aria-describedby="nameHelp">
                                          </div>
                                       </div>
                                       <div class="col-md-6">
                                          <div class="form-group mb-3">
                                             <label for="city">Phone number</label>
                                             <input type="text" name="contact_phone_number[]" id="contact_phone_number" aria-describedby="phonehelp">
                                          </div>
                                       </div>
                                    </div>
                                 </div>
                           </div>
                     
                  @else
                     @foreach(json_decode($livingWillForm->contacts) as $index => $contact)
                              <div class="card list mb-3" id="child">
                                 <div class="card-header">
                                 <div class="card-title">Contact</div>
                                 <a class="r-button" onclick="removetList(this)">
                                    <span class="fas fa-times"></span>
                                    <span class="remove">Remove</span>
                                 </a>
                                 </div>
                                 <div class="card-body">
                                    <div class="row">
                                       <div class="col-md-6">
                                          <div class="form-group mb-3">
                                             <label for="name">Name</label>
                                             <input type="text" name="contact_name[]" id="contact_name_{{$index}}" value="{{ $contact->full_name }}" aria-describedby="nameHelp">
                                          </div>
                                       </div>
                                       <div class="col-md-6">
                                          <div class="form-group mb-3">
                                             <label for="city">Phone number</label>
                                             <input type="text" name="contact_phone_number[]" id="contact_phone_number_{{$index}}" value="{{ $contact->phone_number }}" aria-describedby="phonehelp">
                                          </div>
                                       </div>
                                    </div>
                                 </div>
                           </div>
                     
                     @endforeach
                  @endif
               </div>
               <div class="add-child">
                  <a href="#" class="add-another" id="add-alternate-executor-button" onclick="clone('contact-container')">
                     
                     Add another contact
                  </a>
               </div>
            </div>

         </div>
      </div>
         <!-- start previous / next buttons -->
         <div class="submit-button-multiple">
            @if(isset($livingWillForm->health_care_decisions) && $livingWillForm->health_care_decisions == 'yes')
               <button type="button" onclick="window.location.href = '{{ route('livingwill.create.step.five_3') }}'">Back</button>
            @else
               <button type="button" onclick="window.location.href = '{{ route('livingwill.create.step.four') }}'">Back</button>
            @endif    
            <button type="submit" class="submit-btn">Save and Continue</button>
         
            <button type="submit" name="preview_submit" value="preview" class="d-none">{{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>Why might I want to include a contact list?</p>
         <span class="tooltiptext">Including a contact list in your estate planning documents can be helpful for your loved ones and executor to reach out to relevant parties, such as financial institutions, legal professionals, and family members, in the event of your incapacity or passing.</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