<div class="alert alert-danger d-none hide" id="nurseErrorsBox"></div>
<div class="row">
    <div class="col-md-6">
        <div class="form-group mb-5">
            {{ Form::label('first_name', __('messages.user.first_name') . ':', ['class' => 'form-label']) }}
            <span class="required"></span>
            {{ Form::text('first_name', null, ['class' => 'form-control', 'required']) }}
        </div>
    </div>
    <div class="col-md-6">
        <div class="form-group mb-5">
            {{ Form::label('last_name', __('messages.user.last_name') . ':', ['class' => 'form-label']) }}
            <span class="required"></span>
            {{ Form::text('last_name', null, ['class' => 'form-control', 'required']) }}
        </div>
    </div>
    <div class="col-md-6">
        <div class="form-group mb-5">
            {{ Form::label('email', __('messages.user.email') . ':', ['class' => 'form-label']) }}
            <span class="required"></span>
            {{ Form::email('email', null, ['class' => 'form-control', 'required', 'id' => 'nurseEmail']) }}
        </div>
    </div>
    <div class="col-md-6">
        <div class="form-group mb-5">
            {{ Form::label('designation', __('messages.user.designation') . ':', ['class' => 'form-label']) }}
            <span class="required"></span>
            {{ Form::text('designation', null, ['class' => 'form-control', 'required']) }}
        </div>
    </div>
    <div class="col-md-6">
        <div class="form-group mobile-overlapping mb-5">
            {{ Form::label('phone', __('messages.user.phone') . ':', ['class' => 'form-label']) }}
            <br>
            {{ Form::tel('phone', getCountryCode(), ['class' => 'form-control phoneNumber', 'id' => 'nursePhoneNumber', 'onkeyup' => 'if (/\D/g.test(this.value)) this.value = this.value.replace(/\D/g,"")']) }}
            {{ Form::hidden('prefix_code', null, ['class' => 'prefix_code']) }}
            <span class="text-success valid-msg d-none fw-400 fs-small mt-2">✓ &nbsp; {{ __('messages.valid') }}</span>
            <span class="text-danger error-msg d-none fw-400 fs-small mt-2"></span>
        </div>
    </div>
    <div class="col-md-3">
        <div class="form-group mb-5">
            {{ Form::label('gender', __('messages.user.gender') . ':', ['class' => 'form-label']) }}
            <span class="required"></span> &nbsp;<br>
            <div class="d-flex align-items-center">
                <div class="form-check me-10">
                    <label class="form-label" for="nurseMale">{{ __('messages.user.male') }}</label>
                    {{ Form::radio('gender', '0', true, ['class' => 'form-check-input', 'id' => 'nurseMale']) }}
                </div>
                <div class="form-check me-10">
                    <label class="form-label" for="nurseFemale">{{ __('messages.user.female') }}</label>&nbsp;
                    {{ Form::radio('gender', '1', false, ['class' => 'form-check-input', 'id' => 'nurseFemale']) }}
                </div>
            </div>
        </div>
    </div>
    <div class="col-md-3">
        <div class="form-group mb-5">
            {{ Form::label('status', __('messages.common.status') . ':', ['class' => 'form-label']) }}
            <br>
            <div class="form-check form-switch ">
                <input class="form-check-input w-35px h-20px is-active" name="status" type="checkbox" value="1"
                    checked>
            </div>
        </div>
    </div>
    <div class="col-md-6">
        <div class="form-group mb-5">
            {{ Form::label('qualification', __('messages.user.qualification') . ':', ['class' => 'form-label']) }}
            <span class="required"></span>
            {{ Form::text('qualification', null, ['class' => 'form-control', 'required']) }}
        </div>
    </div>
    <div class="col-md-6">
        <div class="form-group mb-5">
            {{ Form::label('dob', __('messages.user.dob') . ':', ['class' => 'form-label']) }}
            {{ Form::text('dob', null, ['id' => 'nurseBirthDate', 'class' => getLoggedInUser()->thememode ? 'bg-light nurseBirthDate form-control' : 'bg-white nurseBirthDate form-control', 'autocomplete' => 'off']) }}
        </div>
    </div>
    <div class="col-md-6">
        <div class="form-group mb-5">
            {{ Form::label('blood_group', __('messages.user.blood_group') . ':', ['class' => 'form-label']) }}
            {{ Form::select('blood_group', $bloodGroup, null, ['class' => 'form-select', 'id' => 'nurseBloodGroup', 'placeholder' => __('messages.user.select_blood_group')]) }}
        </div>
    </div>
    <div class="col-md-3">
        <div class="form-group mb-5">
            {{ Form::label('password', __('messages.user.password') . ':', ['class' => 'form-label']) }}
            <span class="required"></span>
            {{ Form::password('password', ['class' => 'form-control', 'required', 'min' => '6', 'max' => '10']) }}
        </div>
    </div>
    <div class="col-md-3">
        <div class="form-group mb-5">
            {{ Form::label('password_confirmation', __('messages.user.password_confirmation') . ':', ['class' => 'form-label']) }}
            <span class="required"></span>
            {{ Form::password('password_confirmation', ['class' => 'form-control', 'required', 'min' => '6', 'max' => '10']) }}
        </div>
    </div>
    <div class="form-group col-md-4 mb-5">
        <div class="row2">
            {{ Form::label('image', __('messages.common.profile') . ':', ['class' => 'fs-5 fw-bold mb-2 text-gray-700 d-block']) }}
            <div class="d-block">
                <div class="image-picker">
                    <div class="image previewImage nursePreviewImage" id="nursePreviewImage"
                        style="background-image: url({{ asset('assets/img/avatar.png') }})">
                    </div>
                    <span class="picker-edit rounded-circle text-gray-500 fs-small"
                        title="{{ __('messages.common.profile') }}">
                        <label>
                            <i class="fa-solid fa-pen" id="profileImageIcon"></i>
                            <input type="file" id="nurseProfileImage" name="image"
                                class="image-upload d-none nurseProfileImage" accept=".png, .jpg, .jpeg, .gif" />
                            <input type="hidden" name="avatar_remove">
                        </label>
                    </span>
                </div>
            </div>
        </div>
    </div>
</div>
<hr>
<div class="row mt-3">
    <div class="col-md-12 mb-3">
        <h5>{{ __('messages.user.address_details') }}</h5>
    </div>
    <div class="col-md-6">
        <div class="form-group mb-5">
            {{ Form::label('address1', __('messages.user.address1') . ':', ['class' => 'form-label']) }}
            {{ Form::text('address1', null, ['class' => 'form-control']) }}
        </div>
    </div>
    <div class="col-md-6">
        <div class="form-group mb-5">
            {{ Form::label('address2', __('messages.user.address2') . ':', ['class' => 'form-label']) }}
            {{ Form::text('address2', null, ['class' => 'form-control']) }}
        </div>
    </div>
    <div class="col-md-3">
        <div class="form-group mb-5">
            {{ Form::label('city', __('messages.user.city') . ':', ['class' => 'form-label']) }}
            {{ Form::text('city', null, ['class' => 'form-control']) }}
        </div>
    </div>
    <div class="col-md-3">
        <div class="form-group mb-5">
            {{ Form::label('zip', __('messages.user.zip') . ':', ['class' => 'form-label']) }}
            {{ Form::text('zip', null, ['class' => 'form-control', 'maxlength' => '6', 'minlength' => '6']) }}
        </div>
    </div>
    <div class="d-flex justify-content-end">
        {{ Form::submit(__('messages.common.save'), ['class' => 'btn btn-primary me-3']) }}
        <a href="{{ route('nurses.index') }}" class="btn btn-secondary">{{ __('messages.common.cancel') }}</a>
    </div>
</div>
