@include('includes/header_start')

<!-- Summernote css -->
<link href="{{ asset('assets/plugins/summernote/summernote.css') }}" rel="stylesheet" />

<style>
    iframe {
        overflow: hidden;
    }
</style>

@include('physicians/elements/header_end')

<!-- 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">Billing</h3>
    </li>
</ul>

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

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

<!-- ==================
     PAGE CONTENT START
     ================== -->
<div class="wrap">

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

    <div class="row">
        <div class="col-lg-10 offset-lg-1">

            <div class="card m-b-30">
                <h4 class="card-header mt-0">Fill out billing information</h4>

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

                                <div class="row">
                                    <div class="col-md-6 col-xs-12">

                                        <div class="form-group">
                                            <label>Amount Billed ($)
                                            </label>
                                            <input type="number" min="1" class="form-control" placeholder="E.g. 850" id="amount_billed" name="amount_billed" value="{{ isset($id) ? old('amount_billed', $questionnaire->amount_billed) : old('amount_billed') }}" required>

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

                                        </div>

                                    </div>
                                    <div class="col-md-6 col-xs-12">

                                        <div class="form-group">
                                            <label>Contractual Allowance
                                            </label>
                                            <input type="text" class="form-control" placeholder="Enter the contractual allowance" id="contractual_allowance" name="contractual_allowance" value="{{ isset($id) ? old('contractual_allowance', $questionnaire->contractual_allowance) : old('contractual_allowance') }}" required>

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

                                        </div>
                                    </div>
                                </div>
                                <div class="row">
                                    <div class="col-md-6 col-xs-12">

                                        <div class="form-group">
                                            <label>Net Amount Billed
                                            </label>
                                            <input type="number" min="1" class="form-control" placeholder="Enter the net amount billed" id="net_amount_billed" name="net_amount_billed" value="{{ isset($id) ? old('net_amount_billed', $questionnaire->net_amount_billed) : old('net_amount_billed') }}" required>

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

                                        </div>


                                    </div>
                                    <div class="col-md-6 col-xs-12">

                                        <div class="form-group">
                                            <label>Bank Account Name
                                            </label>
                                            <input type="text" class="form-control" placeholder="Enter the bank account name" id="bank_account_name" name="bank_account_name" value="{{ isset($id) ? old('bank_account_name', $questionnaire->bank_account_name) : old('bank_account_name') }}" required>

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

                                        </div>

                                    </div>
                                </div>
                                <div class="row">
                                    <div class="col-md-6 col-xs-12">

                                        <div class="form-group">
                                            <label>Bank Account Number
                                            </label>
                                            <input type="text" class="form-control" placeholder="Enter your bank account number" id="bank_account_number" name="bank_account_number" value="{{ isset($id) ? old('bank_account_number', $questionnaire->bank_account_number) : old('bank_account_number') }}" required>

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

                                        </div>

        {{--                                <div class="form-group">--}}
        {{--                                    <label>Bank Account Amount Collected--}}
        {{--                                    </label>--}}
        {{--                                    <input type="text" class="form-control" placeholder="Enter the amount collected" id="bank_account_amount_collected" name="bank_account_amount_collected" value="{{ isset($id) ? old('bank_account_amount_collected', $questionnaire->bank_account_amount_collected) : old('bank_account_amount_collected') }}">--}}

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

        {{--                                </div>--}}

                                    </div>
                                    <div class="col-md-6 col-xs-12">

                                        <div class="form-group">
                                            <label>Bank Account Deposited To
                                            </label>
                                            <input type="text" class="form-control" placeholder="Enter the account deposited to" id="bank_account_deposited_to" name="bank_account_deposited_to" value="{{ isset($id) ? old('bank_account_deposited_to', $questionnaire->bank_account_deposited_to) : old('bank_account_deposited_to') }}" required>

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

                                        </div>

                                    </div>
                                </div>
                                <div class="row">
                                    <div class="col-md-6 col-xs-12">

                                        <div class="form-group">
                                            <label>Bank Account Deposit Date
                                            </label>
                                            <input type="date" class="form-control" placeholder="Enter the deposit date" id="datepicker" name="bank_account_deposit_date" value="{{ isset($id) ? old('bank_account_deposit_date', $questionnaire->bank_account_deposit_date) : old('bank_account_deposit_date') }}" required>

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

                                        </div>

                                    </div>
                                    <div class="col-md-6 col-xs-12">

                                    </div>
                                </div>





                                <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>
            </div>
        </div>



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


@include('includes/footer_start')

<!--Summernote js-->
<script src="{{ asset('assets/plugins/summernote/summernote.min.js') }}"></script>

<script>
    jQuery(document).ready(function(){
        $('.summernote').summernote({
            height: 300,                 // set editor height
            minHeight: null,             // set minimum height of editor
            maxHeight: null,             // set maximum height of editor
            focus: true                 // set focus to editable area after initializing summernote
        });
        var el = document.getElementById('submit-form');

        el.addEventListener('submit', function(){
            return confirm('Are you sure you want to submit this form?');
        }, false);

        $('#datepicker').datepicker({
            format: "mm/dd/yyyy",
            language: "en"
        });
    });

</script>

@include('includes/footer_end')