@extends('layouts.app')

@section('bread-crumb')
    <div class="row mb-2">
        <div class="col-sm-6">
        <h1>Create Referral</h1>
        </div>
        <div class="col-sm-6">
        <ol class="breadcrumb float-sm-right">
            <li class="breadcrumb-item"><a href="/dashboard">Dashboard</a></li>
            <li class="breadcrumb-item"><a href="/referrals">Referrals</a></li>
            <li class="breadcrumb-item active">Create Referral</li>
        </ol>
        </div>
    </div>
@endsection

@section('content')
<div class="card card-success card-outline card-tabs">



    @if (Auth::user()->role == 2)
        <form class="form-horizontal" method="POST" action="/referral/direct_refer" enctype="multipart/form-data">
    @else
        @isset($_GET['internal'])
            <form class="form-horizontal" method="POST" action="/patient/walkin" enctype="multipart/form-data">
        @else
            @if (Auth::user()->role == 1)
                <div class="card-header">
                    <a href="/print-blank-referral" class="btn btn-danger" title="Print blank referral form">
                        <i class="fa fa-print"></i> PRINT
                    </a>
                </div>
            @endif
            <form class="form-horizontal" method="POST" action="/referral" enctype="multipart/form-data">
        @endisset
    @endif

        @csrf
        <div class="card-body p-5">
            <h3 class="text-center">HEALTH REFERRAL FORM</h3>
            @isset($_GET['internal'])
                <h5 class="text-center mb-5 text-muted font-italic">-ADD PATIENT DETAILS-</h5>
            @endisset

            @if ($errors->any())
                <div class="alert alert-danger">
                    <ul>
                        @foreach ($errors->all() as $error)
                            <li>{{ $error }}</li>
                        @endforeach
                    </ul>
                </div>
            @endif

            @if (session()->has('referral.store'))
                @if (session()->get('referral.store'))
                    <div class="alert alert-success alert-dismissible col-12" id="alert">
                        <button type="button" class="close" data-dismiss="alert" aria-hidden="true">&times;</button>
                        <h5><i class="icon fas fa-check"></i> Success!</h5>
                        New referral successfully added
                    </div>
                @endif
            @endif

            @if (Auth::user()->role == 1)


                @isset($_GET['internal'])
                    @isset($_GET['bed_id'])
                        <div class="form-group row">
                            <label for="ref_from_hospital" class="col-sm-2 col-form-label">BED DETAILS</label>
                            <div class="col-sm-10">
                                <input type="text" class="form-control font-italic text-uppercase" value="{{$station->station}} | {{$room->room}} | {{$bed->bed}}" readonly>
                                <input type="hidden" name="bed_id" value="{{$bed->id}}">
                            </div>
                        </div>
                    @else
                        <div class="form-group row">
                            <label for="ref_from_hospital" class="col-sm-2 col-form-label">BED DETAILS</label>
                            <div class="col-sm-10">
                                <input type="text" class="form-control font-italic text-uppercase" value="{{$dept_bed->type}} | {{$dept_bed->bed}} | {{$dept_bed->description}}" readonly>
                                <input type="hidden" name="dept_bed_id" value="{{$dept_bed->id}}">
                            </div>
                        </div>
                    @endisset
                @else
                    <div class="form-group row">
                        <label for="ref_from_hospital" class="col-sm-2 col-form-label">REFERRING HOSPITAL</label>
                        <div class="col-sm-10">
                            <input type="hidden" class="form-control" id="ref_from_hospital" name="ref_from_hospital" value="{{$hospital->id}}">
                            <input type="text" class="form-control" value="{{$hospital->hospital}}" readonly>
                        </div>
                    </div>
                @endisset
            @endif

            @if (Auth::user()->role == 4)
                <div class="form-group row">
                    <label for="ref_from_hospital" class="col-sm-2 col-form-label">REFERRING CITY/MUNICIPALITY</label>
                    <div class="col-sm-10">
                        <input type="hidden" class="form-control" id="ref_from_drrmo" name="ref_from_drrmo" value="{{$drrmo->id}}">
                        <input type="text" class="form-control" value="{{$drrmo->drrmo}}" readonly>
                    </div>
                </div>
            @endif

            @if (Auth::user()->role == 2)
                <input type="hidden" class="form-control" id="ref_to_hospital" name="ref_to_hospital" value="">

                                @if ($bed_id)
                    <input type="hidden" class="form-control" id="bed_id" name="bed_id" value="">
                @else
                    <input type="hidden" class="form-control" id="dept_bed_id" name="dept_bed_id" value="">
                @endif
            @endif

            <div class="form-group row">
                <label for="patient_name" class="col-sm-2 col-form-label">PATIENT NAME *</label>
                <div class="col-sm-10">
                    <input type="text" class="form-control" id="patient" name="patient" value="{{ old('patient') }}" placeholder="-" required>
                    @error('patient')
                        <span>
                            {{ $message }}
                        </span>
                    @enderror
                </div>
            </div>

            <div class="form-group row">
                <label for="birthdate" class="col-sm-2 col-form-label">BIRTHDATE *</label>
                <div class="col-sm-10">
                    <input type="date" class="form-control" name="birthdate" id="birthdate" value="{{ old('birthdate') }}" required>
                </div>
            </div>

            <div class="form-group row">
                <label for="age" class="col-sm-2 col-form-label">AGE</label>
                <div class="col-sm-10">
                    <input type="text" class="form-control" name="age" id="age" value="{{ old('age') }}" placeholder="-" readonly>
                    @error('age')
                        <span>
                            {{ $message }}
                        </span>
                    @enderror
                </div>
            </div>

            <div class="form-group row">
                <label for="sex" class="col-sm-2 col-form-label">SEX *</label>
                <div class="col-sm-10">
                    <select class="form-control select2" name="sex" style="width: 100%;" required>
                        <option selected="selected" value="">Please select a sex</option>
                        <option value="male" @if(old('sex') == 'male') selected @endif>Male</option>
                        <option value="female" @if(old('sex') == 'female') selected @endif>Female</option>
                    </select>
                    @error('sex')
                        <span>
                            {{ $message }}
                        </span>
                    @enderror
                </div>
            </div>

            <div class="form-group row">
                <label for="civil_status" class="col-sm-2 col-form-label">CIVIL STATUS</label>
                <div class="col-sm-10">
                    <select class="form-control select2" name="civil_status" style="width: 100%;">
                        <option selected="selected" value="">Please select a civil status</option>
                        <option value="single">Single</option>
                        <option value="married">Married</option>
                        <option value="separated">Separated</option>
                        <option value="divorced">Divorce</option>
                        <option value="widowed">Widowed</option>
                    </select>
                </div>
            </div>

            <div class="form-group row">
                <label for="address" class="col-sm-2 col-form-label">ADDRESS *</label>
                <div class="col-sm-10">
                    <input type="text" class="form-control" name="address" value="{{ old('address') }}" placeholder="-" required>
                    @error('address')
                        <span>
                            {{ $message }}
                        </span>
                    @enderror
                </div>
            </div>

            <div class="form-group row">
                <label for="occupation" class="col-sm-2 col-form-label">OCCUPATION</label>
                <div class="col-sm-10">
                    <input type="text" class="form-control" name="occupation" placeholder="-">
                </div>
            </div>

            <div class="form-group row">
                <label for="religion" class="col-sm-2 col-form-label">RELIGION</label>
                <div class="col-sm-10">
                    <input type="text" class="form-control" name="religion" placeholder="-">
                </div>
            </div>

            <div class="form-group row">
                <label for="guardian" class="col-sm-2 col-form-label">GUARDIAN *</label>
                <div class="col-sm-10">
                    <input type="text" class="form-control" name="guardian" value="{{ old('guardian') }}" placeholder="-" required>
                    @error('guardian')
                        <span>
                            {{ $message }}
                        </span>
                    @enderror
                </div>
            </div>

            <div class="form-group row">
                <label for="" class="col-sm-2 col-form-label"></label>
                <div class="col-sm-10">
                    <div class="form-group clearfix">
                        <div class="icheck-success d-inline mr-3">
                            <input type="radio" name="state" id="state1" value="pwd">
                            <label for="state1">
                                PWD
                            </label>
                        </div>
                        <div class="icheck-success d-inline mr-3">
                            <input type="radio" name="state" id="state2" value="sc">
                            <label for="state2">
                                SC
                            </label>
                        </div>
                        <div class="icheck-success d-inline">
                            <input type="radio" name="state" id="state3" value="ic">
                            <label for="state3">
                                IC
                            </label>
                        </div>
                      </div>
                </div>
            </div>

            <div class="form-group row">
                <label class="col-sm-2 col-form-label">CHIEF COMPLAINT *</label>
                <div class="col-sm-10">
                    <textarea class="form-control" rows="3" name="complaint" placeholder="-" required>{{ old('complaint') }}</textarea>
                    @error('complaint')
                        <span>
                            {{ $message }}
                        </span>
                    @enderror
                </div>
            </div>

            <div class="form-group row">
                <label for="inputPassword3" class="col-sm-2 col-form-label">VITAL SIGNS</label>
                <div class="col-sm-10 row">
                    <div class="col-sm-4">
                        <div class="form-group">
                            <label class="font-weight-normal">BP</label>
                            <input type="text" class="form-control form-control-sm" name="vs_bp" value="{{ old('vs_bp') }}" placeholder="-">
                        </div>
                    </div>

                    <div class="col-sm-4">
                        <div class="form-group">
                            <label class="font-weight-normal">HR</label>
                            <input type="text" class="form-control form-control-sm" name="vs_hr" value="{{ old('vs_hr') }}" placeholder="-">
                        </div>
                    </div>

                    <div class="col-sm-4">
                        <div class="form-group">
                            <label class="font-weight-normal">RR</label>
                            <input type="text" class="form-control form-control-sm" name="vs_rr" value="{{ old('vs_rr') }}" placeholder="-">
                        </div>
                    </div>

                    <div class="col-sm-4">
                        <div class="form-group">
                            <label class="font-weight-normal">TEMP</label>
                            <input type="text" class="form-control form-control-sm" name="vs_temp" value="{{ old('vs_temp') }}" placeholder="-">
                        </div>
                    </div>

                    <div class="col-sm-4">
                        <div class="form-group">
                            <label class="font-weight-normal">WEIGHT</label>
                            <input type="text" class="form-control form-control-sm" name="vs_weight" value="{{ old('vs_weight') }}" placeholder="-">
                        </div>
                    </div>
                </div>
            </div>

            <div class="form-group row">
                <label for="inputPassword3" class="col-sm-2 col-form-label">OB HISTORY</label>
                <div class="col-sm-10 row">
                    <div class="col-sm-4">
                        <div class="form-group">
                            <label class="font-weight-normal">G</label>
                            <input type="text" class="form-control form-control-sm" name="obh_g" value="{{ old('obh_g') }}" placeholder="-">
                        </div>
                    </div>

                    <div class="col-sm-4">
                        <div class="form-group">
                            <label class="font-weight-normal">P</label>
                            <input type="text" class="form-control form-control-sm" name="obh_p" value="{{ old('obh_p') }}" placeholder="-">
                        </div>
                    </div>

                    <div class="col-sm-4">
                        <div class="form-group">
                            <label class="font-weight-normal">LMP</label>
                            <input type="text" class="form-control form-control-sm" name="obh_lmp" value="{{ old('obh_lmp') }}" placeholder="-">
                        </div>
                    </div>

                    <div class="col-sm-4">
                        <div class="form-group">
                            <label class="font-weight-normal">EDC</label>
                            <input type="text" class="form-control form-control-sm" name="obh_edc" value="{{ old('obh_edc') }}" placeholder="-">
                        </div>
                    </div>

                    <div class="col-sm-4">
                        <div class="form-group">
                            <label class="font-weight-normal">AOG</label>
                            <input type="text" class="form-control form-control-sm" name="obh_aog" value="{{ old('obh_aog') }}" placeholder="-">
                        </div>
                    </div>

                    <div class="col-sm-4">
                        <div class="form-group">
                            <label class="font-weight-normal">FH</label>
                            <input type="text" class="form-control form-control-sm" name="obh_fh" value="{{ old('obh_fh') }}" placeholder="-">
                        </div>
                    </div>

                    <div class="col-sm-4">
                        <div class="form-group">
                            <label class="font-weight-normal">FHR</label>
                            <input type="text" class="form-control form-control-sm" name="obh_fhr" value="{{ old('obh_fhr') }}" placeholder="-">
                        </div>
                    </div>

                    <div class="col-sm-4">
                        <div class="form-group">
                            <label class="font-weight-normal">PELVIC</label>
                            <input type="text" class="form-control form-control-sm" name="obh_pelvic" value="{{ old('obh_pelvic') }}" placeholder="-">
                        </div>
                    </div>
                </div>
            </div>

            <div class="form-group row">
                <label for="inputPassword3" class="col-sm-2 col-form-label">BRIEF HX & PE</label>
                <div class="col-sm-10">
                    <textarea class="form-control" rows="3" name="hx_n_pe" placeholder="-">{{ old('hx_n_pe') }}</textarea>
                </div>
            </div>

            <div class="form-group row">
                <label for="inputPassword3" class="col-sm-2 col-form-label">IMPRESSION OR DIAGNOSIS *</label>
                <div class="col-sm-10">
                    <textarea class="form-control" rows="3" name="diagnosis" placeholder="-" required>{{ old('diagnosis') }}</textarea>
                    @error('diagnosis')
                        <span>
                            {{ $message }}
                        </span>
                    @enderror
                </div>
            </div>

            <div class="form-group row">
                <label for="inputPassword3" class="col-sm-2 col-form-label">MEDICATION/TREATMENT</label>
                <div class="col-sm-10">
                    <textarea class="form-control" rows="3" name="medication" placeholder="-">{{ old('medication') }}</textarea>
                </div>
            </div>

            <div class="form-group row">
                <label for="inputPassword3" class="col-sm-2 col-form-label">REASON FOR REFERRAL *</label>
                <div class="col-sm-10 row">
                    <div class="col-sm-4 mb-2">
                        <div class="icheck-success d-inline">
                            <input type="radio" name="reason" id="reason1" value="Further evaluation and management" @if(old('reason') == 'Further evaluation and management') checked @endif>
                            <label for="reason1" class="font-weight-normal">
                                Further evaluation and management
                            </label>
                        </div>
                    </div>

                    <div class="col-sm-4 mb-2">
                        <div class="icheck-success d-inline">
                            <input type="radio" name="reason" id="reason2" value="For Work-up" @if(old('reason') == 'For Work-up') checked @endif>
                            <label for="reason2" class="font-weight-normal">
                                For Work-up
                            </label>
                        </div>
                    </div>

                    <div class="col-sm-4 mb-2">
                        <div class="icheck-success d-inline">
                            <input type="radio" name="reason" id="reason3" value="For Medico-legal" @if(old('reason') == 'For Medico-legal') checked @endif>
                            <label for="reason3" class="font-weight-normal">
                                For Medico-legal
                            </label>
                        </div>
                    </div>

                    <div class="col-sm-4 mb-2">
                        <div class="icheck-success d-inline">
                            <input type="radio" name="reason" id="reason4" value="Isolation" @if(old('reason') == 'Isolation') checked @endif>
                            <label for="reason4" class="font-weight-normal">
                                Isolation
                            </label>
                        </div>
                    </div>

                    <div class="col-sm-4 mb-2">
                        <div class="icheck-success d-inline">
                            <input type="radio" name="reason" id="reason5" value="Patient's Request" @if(old('reason') == "Patient's Request") checked @endif>
                            <label for="reason5" class="font-weight-normal">
                                Patient's Request
                            </label>
                        </div>
                    </div>

                    <div class="col-sm-4 mb-2">
                        <div class="icheck-success d-inline">
                            <input type="radio" name="reason" id="reason6" value="OPD Consult" @if(old('reason') == 'OPD Consult') checked @endif>
                            <label for="reason6" class="font-weight-normal">
                                OPD Consult
                            </label>
                        </div>
                    </div>

                    {{-- <div class="col-sm-12">
                        <div class="form-group">
                            <label class="font-weight-normal">OTHERS</label>
                            <textarea class="form-control" rows="3" name="reason" placeholder="-"></textarea>
                        </div>
                    </div> --}}
                    @error('reason')
                        <span>
                            {{ $message }}
                        </span>
                    @enderror
                </div>
            </div>

            <div class="form-group row">
                <label class="col-sm-2 col-form-label">O2 SAT</label>
                <div class="col-sm-10">
                    <input type="text" class="form-control" name="o2_sat" value="{{old('o2_sat')}}" placeholder="-">
                </div>
            </div>
            

            <div class="form-group row">
                <label class="col-sm-2 col-form-label">REFERRAL TYPE *</label>
                <div class="col-sm-10">
                    <div class="form-group clearfix">
                        <div class="icheck-success d-inline mr-3">
                            <input type="radio" name="referral_type" id="referral_type1" value='Pedia'>
                            <label for="referral_type1" class="font-weight-normal">
                                Pedia
                            </label>
                        </div>
                        <div class="icheck-success d-inline mr-3">
                            <input type="radio" name="referral_type" id="referral_type2" value='Medicine'>
                            <label for="referral_type2" class="font-weight-normal">
                                Medical
                            </label>
                        </div>
                        <div class="icheck-success d-inline mr-3">
                            <input type="radio" name="referral_type" id="referral_type3" value='OB Gyne'>
                            <label for="referral_type3" class="font-weight-normal">
                                OB Gyne
                            </label>
                        </div>
                        <div class="icheck-success d-inline mr-3">
                            <input type="radio" name="referral_type" id="referral_type4" value='Surgery'>
                            <label for="referral_type4" class="font-weight-normal">
                                Surgery
                            </label>
                        </div>
                        <div class="icheck-success d-inline mr-3">
                            <input type="radio" name="referral_type" id="referral_type5" value='COVID 19'>
                            <label for="referral_type5" class="font-weight-normal">
                                COVID 19
                            </label>
                        </div>
                    </div>
                </div>
            </div>

            <hr>

            <div class="form-group row">
                <label class="col-sm-2 col-form-label">RAT RESULT</label>
                <div class="col-sm-10">
                    <div class="form-group clearfix">
                        <div class="icheck-success d-inline mr-3">
                            <input type="radio" name="rat" id="rat1" value='+'>
                            <label for="rat1" class="font-weight-normal">
                                POSITIVE
                            </label>
                        </div>
                        <div class="icheck-success d-inline mr-3">
                            <input type="radio" name="rat" id="rat2" value='-'>
                            <label for="rat2" class="font-weight-normal">
                                NEGATIVE
                            </label>
                        </div>
                        <div class="icheck-success d-inline mr-3">
                            <input type="radio" name="rat" id="ratna" value='na'>
                            <label for="ratna" class="font-weight-normal">
                                NA
                            </label>
                        </div>
                      </div>
                </div>
            </div>

            <div class="form-group row">
                <label class="col-sm-2 col-form-label">RAT ATTACHMENT</label>
                <div class="col-sm-10">
                    <input type="file" accept="image/*" name="rat_attach" id="rat_attach">
                    <button class="btn btn-sm btn-default d-none col-md-2" id="rat_view_btn" data-toggle="modal" data-target="#ratView">
                        <i class="fa fa-file-image"></i>
                         VIEW ATTACHED FILE
                    </button>

                    <!-- Modal -->
                    <div class="modal fade" id="ratView" tabindex="-1" role="dialog" aria-labelledby="ratViewTitle" aria-hidden="true">
                        <div class="modal-dialog modal-dialog-centered modal-lg" role="document">
                        <div class="modal-content">
                            <div class="modal-header">
                                <button type="button" class="close" data-dismiss="modal" aria-label="Close">
                                    <span aria-hidden="true">&times;</span>
                                </button>
                            </div>
                            <div class="modal-body">
                                <img src="" class="img-fluid" id="rat_preview">
                            </div>
                            <div class="modal-footer justify-content-center">
                                <button type="button" class="btn btn-sm btn-danger col-md-2" id="rat_remove" data-dismiss="modal">REMOVE</button>
                            </div>
                        </div>
                        </div>
                    </div>
                    <!-- Modal -->
                </div>
            </div>

            <hr>

            <div class="form-group row">
                <label class="col-sm-2 col-form-label">RT-PCR RESULT</label>
                <div class="col-sm-10">
                    <div class="form-group clearfix">
                        <div class="icheck-success d-inline mr-3">
                            <input type="radio" name="rtpcr" id="rtpcr1" value='+'>
                            <label for="rtpcr1" class="font-weight-normal">
                                POSITIVE
                            </label>
                        </div>
                        <div class="icheck-success d-inline mr-3">
                            <input type="radio" name="rtpcr" id="rtpcr2" value='-'>
                            <label for="rtpcr2" class="font-weight-normal">
                                NEGATIVE
                            </label>
                        </div>
                        <div class="icheck-success d-inline mr-3">
                            <input type="radio" name="rtpcr" id="na" value='na'>
                            <label for="na" class="font-weight-normal">
                                NA
                            </label>
                        </div>
                      </div>
                </div>
            </div>

            <div class="form-group row">
                <label class="col-sm-2 col-form-label">RT-PCR ATTACHMENT</label>
                <div class="col-sm-10">
                    <input type="file" accept="image/*" name="rtpcr_attach" id="rtpcr_attach">
                    <button class="btn btn-sm btn-default d-none col-md-2" id="rtpcr_view_btn" data-toggle="modal" data-target="#rtpcrView">
                        <i class="fa fa-file-image"></i>
                         VIEW ATTACHED FILE
                    </button>

                    <!-- Modal -->
                    <div class="modal fade" id="rtpcrView" tabindex="-1" role="dialog" aria-labelledby="rtpcrViewTitle" aria-hidden="true">
                        <div class="modal-dialog modal-dialog-centered modal-lg" role="document">
                        <div class="modal-content">
                            <div class="modal-header">
                                <button type="button" class="close" data-dismiss="modal" aria-label="Close">
                                    <span aria-hidden="true">&times;</span>
                                </button>
                            </div>
                            <div class="modal-body">
                                <img src="" class="img-fluid" id="rtpcr_preview">
                            </div>
                            <div class="modal-footer justify-content-center">
                                <button type="button" class="btn btn-sm btn-danger col-md-2" id="rtpcr_remove" data-dismiss="modal">REMOVE</button>
                            </div>
                        </div>
                        </div>
                    </div>
                    <!-- Modal -->
                </div>
            </div>

            <hr>

            <div class="form-group row">
                <label class="col-sm-2 col-form-label">ADDITIONAL INSTRUCTION</label>
                <div class="col-sm-10">
                    <textarea class="form-control" rows="3" name="add_instruction" placeholder="-">{{ old('add_instruction') }}</textarea>
                </div>
            </div>

            <div class="form-group row">
                <label class="col-sm-2 col-form-label">VACCINATION</label>
                <div class="col-sm-10">
                    <div class="form-group clearfix">
                        <div class="icheck-success d-inline mr-3">
                            <input type="checkbox" name="vaccine_1st_dose" id="vaccine_1st_dose">
                            <label for="vaccine_1st_dose" class="font-weight-normal">
                                1st Dose
                            </label>
                        </div>
                        <div class="icheck-success d-inline mr-3">
                            <input type="checkbox" name="vaccine_2nd_dose" id="vaccine_2nd_dose">
                            <label for="vaccine_2nd_dose" class="font-weight-normal">
                                2nd Dose
                            </label>
                        </div>
                      </div>
                </div>
            </div>

            <div class="form-group row">
                <label class="col-sm-2 col-form-label">PHIC ID NO.</label>
                <div class="col-sm-10">
                    <input type="text" class="form-control" name="phic_id_no" value="{{old('phic_id_no')}}" placeholder="-">
                </div>
            </div>

            <div class="form-group row">
                <label for="inputPassword3" class="col-sm-2 col-form-label">REFERRED BY *</label>
                <div class="col-sm-10">
                    <input type="text" class="form-control" name="ref_by" value="{{old('ref_by')}}" placeholder="-" required>
                    @error('ref_by')
                        <span>
                            {{ $message }}
                        </span>
                    @enderror
                </div>
            </div>

            <div class="form-group row">
                <label for="inputPassword3" class="col-sm-2 col-form-label">CONTACT NO.  *</label>
                <div class="col-sm-10">
                    <input type="text" class="form-control" name="contact_no" value="{{old('contact_no')}}" placeholder="-" required>
                    @error('contact_no')
                        <span>
                            {{ $message }}
                        </span>
                    @enderror
                </div>
            </div>

            @isset($_GET['internal'])
                <div class="form-group row">
                    <label for="inputPassword3" class="col-sm-2 col-form-label">REMARKS </label>
                    <div class="col-sm-10">
                        <textarea class="form-control" rows="6" name="remarks" placeholder="-">{{ old('remarks') }}</textarea>
                        @error('remarks')
                            <span>
                                {{ $message }}
                            </span>
                        @enderror
                    </div>
                </div>
            @endisset

        </div>
        <div class="card-footer justify-content-center text-center">
            <button type="submit" class="btn btn-info">SUBMIT</button>
            <a href="/referrals" class="btn btn-default">CANCEL</a>
        </div>

        <span id="bdate"></span>
    </form>
</div>
@endsection

@section('script')
    <script>
        $(function () {


            //Initialize Select2 Elements
            $('.select2').select2()


            $('#rtpcr_attach').on('change', function() {
                $input = $(this);
                if($input.val().length > 0) {
                    fileReader = new FileReader();
                    fileReader.onload = function (data) {
                    $('#rtpcr_preview').attr('src', data.target.result);
                    }
                    fileReader.readAsDataURL($input.prop('files')[0]);
                }
                $(this).addClass('d-none')
                $('#rtpcr_view_btn').removeClass('d-none')
            });
                                    
            $('#rtpcr_remove').on('click', function() {
                $('#rtpcr_attach').val('');	
                $('#rtpcr_attach').removeClass('d-none');	
                $('#rtpcr_view_btn').addClass('d-none')
            });

            $('#rat_attach').on('change', function() {
                $input = $(this);
                if($input.val().length > 0) {
                    fileReader = new FileReader();
                    fileReader.onload = function (data) {
                    $('#rat_preview').attr('src', data.target.result);
                    }
                    fileReader.readAsDataURL($input.prop('files')[0]);
                }
                $(this).addClass('d-none')
                $('#rat_view_btn').removeClass('d-none')
            });
                                    
            $('#rat_remove').on('click', function() {
                $('#rat_attach').val('');	
                $('#rat_attach').removeClass('d-none');	
                $('#rat_view_btn').addClass('d-none')
            });


        });
    </script>
@endsection