@include('includes/header_start')

<link href="{{ asset('assets/plugins/select2/css/select2.min.css') }}" rel="stylesheet" type="text/css" />

@include('includes/header_end')
<style type="text/css" media="print">
    @page
    {
        size: auto;   /* auto is the initial value */
        margin: 0mm;  /* this affects the margin in the printer settings */
    }
    @media print
    {
        .no-print, .no-print *
        {
            display: none !important;
        }
    }
</style>
<!-- Page title -->
<ul class="list-inline menu-left mb-0">
    <li class="list-inline-item">
        <button type="button" class="button-menu-mobile open-left waves-effect">
            <i class="ion-navicon"></i>
        </button>
    </li>
    <li class="hide-phone list-inline-item app-search">
        <h3 class="page-title">Invoice</h3>
    </li>
</ul>

<div class="clearfix"></div>
</nav>

</div>
<!-- Top Bar End -->

<!-- ==================
     PAGE CONTENT START
     ================== -->

<div class="page-content-wrapper">

    <div class="container-fluid">

        <div class="row">
            <div class="col-12">
                <div class="card m-b-20">
                    <div class="card-body">

                        <form action="{{ isset($id) ?  route('calls.videochat.billing.store', Request::segment(3)) :  route('calls.videochat.billing.store', Request::segment(3)) }} " method="POST" enctype="multipart/form-data" autocomplete="off">
                            @csrf

                            <div class="row">
                                <div class="col-12">
                                    <div class="invoice-title">
    {{--                                    <h4 class="pull-right font-16"><strong>Order # 12345</strong></h4>--}}
                                        <div class="row">
                                            <div class="mt-0 col-lg-6">
        {{--                                        <img src="assets/images/logo_dark.png" alt="logo" height="26"/>--}}
                                                <img src="{{ asset('assets/images/h3a-logo-bg.jpg') }}"alt="logo" style="width:200px;">
                                            </div>
                                            <div class="col-lg-6">
                                                <h1 class="m-0 pull-right" style="">
                                                    Total:
                                                    @if($bill->amount_billed === NULL)
                                                        {{ $bill->amount_billed }}<br>
                                                    @else
                                                        <input type="number" min="1" class="form-control no-print" placeholder="Amount Billed" id="amount_billed" name="amount_billed" required>
                                                    @endif
    {{--                                                {{ "$".$bill->amount_billed }}--}}
                                                </h1>
                                            </div>
                                        </div>
                                    </div>
                                    <hr>
                                    <div class="row">
                                        <div class="col-6">
                                            <address>
                                                <strong>Payee Details:</strong><br>
                                                {{ $bill->payee_name }}<br>
                                                {{ $bill->payee_address1 }}<br>
                                                {{ $bill->payee_city }}<br>
                                                {{ $bill->payee_state }}<br>
                                                {{ $bill->payee_zipcode }}<br>
                                                {{ $bill->payee_tel }}
                                            </address>
                                        </div>
                                        <div class="col-6 text-right">
                                            <address>
                                                <strong>Payment Method:</strong><br>
                                                Bank Account Name<br>
                                                @if($bill->bank_account_name === NULL)
                                                    {{ $bill->bank_account_name }}<br>
                                                @else
                                                    <input type="text" class="form-control no-print" placeholder="Bank Account Name" id="bank_account_name" name="bank_account_name" required autocomplete="off"><br>
                                                @endif
                                                Bank Account Number<br>
                                                @if($bill->bank_account_number === NULL)
                                                    {{ $bill->bank_account_number }}<br>
                                                @else
                                                    <input type="text" class="form-control no-print" placeholder="Bank Account Number" id="bank_account_number" name="bank_account_number" required autocomplete="off">
                                                @endif
                                            </address>
                                        </div>
                                    </div>
                                    <div class="row">
                                        <div class="col-12 m-t-30 text-right">
                                            <address>
                                                <strong>Bill Created:</strong><br>
                                                {{ date('jS M Y', strtotime($bill->created_at)) }}<br><br>
                                            </address>
                                        </div>
                                    </div>
                                </div>
                            </div>

    {{--                        <div class="row">--}}
    {{--                            <div class="col-12">--}}
    {{--                                @foreach($cptCodes as $code)--}}
    {{--                                    <div class="form-check">--}}
    {{--                                        <input class="form-check-input" type="checkbox" value="" id="defaultCheck1" name="{{ $code->id }}">--}}
    {{--                                        <label class="form-check-label" for="defaultCheck1">--}}
    {{--                                            {{ $code->cpt_code }} - {{ $code->cpt_description }}--}}
    {{--                                        </label>--}}
    {{--                                    </div>--}}
    {{--                                @endforeach--}}
    {{--                            </div>--}}
    {{--                        </div>--}}


                            <div class="row no-print">
                                <div class="col-12">
                                    <div class="form-group">
                                        <label for="example-text-input" class="col-sm-12" style="text-align:center;">CPT Codes</label>
                                        <div class="col-sm-12 offset-sm-12">
                                            <select class="select2 form-control" id="cpt_codes" multiple="multiple" name="cpt_codes" data-placeholder="Choose ...">
                                                <option value="">Select</option>
                                                @foreach($cptCodes as $code)
                                                    <option value="{{ $code->cpt_code }}" {{in_array( $code->cpt_code, old("dialysis_days") ?: []) ? "selected": ""}}>{{ $code->cpt_code }} - {{ $code->cpt_description }}</option>
                                                @endforeach
                                            </select>

                                            @if ($errors->has('have_asthma'))
                                                <span class="badge badge-danger">{{ $errors->first('have_asthma') }}</span>
                                            @endif

                                        </div>
                                    </div>
                                </div>
                            </div>

                            <div class="row">
                                <div class="col-12">
                                    <div class="panel panel-default">
                                        <div class="p-2">
                                            <h3 class="panel-title font-20"><strong>Physician Comments</strong></h3>
                                        </div>
                                        <div class="">
                                            <div class="table-responsive">
                                                <table class="table">
                                                    <thead>
                                                    <tr>
                                                        <td><strong>Form</strong></td>
                                                        <td class="text-center"><strong>Physician Comments</strong></td>
                                                        <td class="text-center"><strong></strong></td>
                                                        <td class="text-center"><strong></strong></td>
                                                    </tr>
                                                    </thead>
                                                    <tbody>
                                                    <!-- foreach ($order->lineItems as $line) or some such thing here -->
                                                    <tr>
                                                        <td>General Comments</td>
                                                        <td class="text-center">{!! $bill->general['physician_comments'] !!}  </td>
                                                        <td class="text-center"></td>
                                                        <td class="text-center"></td>
                                                    </tr>
                                                    <tr>
                                                        <td>Cardiac Comments</td>
                                                        <td class="text-center">{!! $bill->cardiac['physician_comments'] !!}  </td>
                                                        <td class="text-center"></td>
                                                        <td class="text-center"></td>
                                                    </tr>
                                                    <tr>
                                                        <td>Endocrine Comments</td>
                                                        <td class="text-center">{!! $bill->endocrine['physician_comments'] !!}  </td>
                                                        <td class="text-center"></td>
                                                        <td class="text-center"></td>
                                                    </tr>
                                                    <tr>
                                                        <td>Gastrointestinal Comments</td>
                                                        <td class="text-center">{!! $bill->gastrointestinal['physician_comments'] !!}  </td>
                                                        <td class="text-center"></td>
                                                        <td class="text-center"></td>
                                                    </tr>
                                                    <tr>
                                                        <td>Miscellaneous Comments</td>
                                                        <td class="text-center">{!! $bill->misc['physician_comments'] !!}  </td>
                                                        <td class="text-center"></td>
                                                        <td class="text-center"></td>
                                                    </tr>
                                                    <tr>
                                                        <td>Neurological Comments</td>
                                                        <td class="text-center">{!! $bill->neurological['physician_comments'] !!}  </td>
                                                        <td class="text-center"></td>
                                                        <td class="text-center"></td>
                                                    </tr>
                                                    <tr>
                                                        <td>Pulmonary Comments</td>
                                                        <td class="text-center">{!! $bill->pulmonary['physician_comments'] !!}  </td>
                                                        <td class="text-center"></td>
                                                        <td class="text-center"></td>
                                                    </tr>
                                                    <tr>
                                                        <td>Renal Comments</td>
                                                        <td class="text-center">{!! $bill->renal['physician_comments'] !!}  </td>
                                                        <td class="text-center"></td>
                                                        <td class="text-center"></td>
                                                    </tr>
    {{--                                                <tr>--}}
    {{--                                                    <td>BS-400</td>--}}
    {{--                                                    <td class="text-center">$20.00</td>--}}
    {{--                                                    <td class="text-center">3</td>--}}
    {{--                                                    <td class="text-right">$60.00</td>--}}
    {{--                                                </tr>--}}
    {{--                                                <tr>--}}
    {{--                                                    <td>BS-1000</td>--}}
    {{--                                                    <td class="text-center">$600.00</td>--}}
    {{--                                                    <td class="text-center">1</td>--}}
    {{--                                                    <td class="text-right">$600.00</td>--}}
    {{--                                                </tr>--}}
    {{--                                                <tr>--}}
    {{--                                                    <td class="thick-line"></td>--}}
    {{--                                                    <td class="thick-line"></td>--}}
    {{--                                                    <td class="thick-line text-center">--}}
    {{--                                                        <strong>Subtotal</strong></td>--}}
    {{--                                                    <td class="thick-line text-right">$670.99</td>--}}
    {{--                                                </tr>--}}
    {{--                                                <tr>--}}
    {{--                                                    <td class="no-line"></td>--}}
    {{--                                                    <td class="no-line"></td>--}}
    {{--                                                    <td class="no-line text-center">--}}
    {{--                                                        <strong>Shipping</strong></td>--}}
    {{--                                                    <td class="no-line text-right">$15</td>--}}
    {{--                                                </tr>--}}
                                                    <tr>
                                                        <td class="no-line"></td>
                                                        <td class="no-line"></td>
                                                        <td class="no-line pull-right">
                                                            <strong>Total</strong></td>
                                                        <td class="no-line text-right"><h4 class="m-0">{{ "$".$bill->amount_billed }}</h4></td>
                                                    </tr>
                                                    </tbody>
                                                </table>
                                            </div>

                                            <div class="d-print-none">
                                                <div class="pull-right">
                                                    <a href="javascript:window.print()" class="btn btn-success waves-effect waves-light"><i class="fa fa-print"></i></a>
                                                    <a href="#" class="btn btn-primary waves-effect waves-light">Send</a>
                                                </div>
                                            </div>
                                        </div>
                                    </div>

                                </div>
                            </div> <!-- end row -->

                            <div class="row">
                                <div class="col-md-12">
                                    <button type="submit" class="btn btn-primary btn-flat pull-right">Submit</button>
                                </div>
                            </div>

                        </form>

                    </div>
                </div>
            </div> <!-- end col -->
        </div> <!-- end row -->


    </div><!-- container -->

</div> <!-- Page content Wrapper -->

</div> <!-- content -->

@include('includes/footer_start')
<script src="{{ asset('assets/plugins/select2/js/select2.min.js') }}" type="text/javascript"></script>

<script>
    $(function(){
        $(".select2").select2();
    });

</script>
@include('includes/footer_end')