@extends('collector.layouts.master') @section('content') Patient Details @csrf Name* {{-- First Name --}} @if ($errors->has('fname')) {{ $errors->first('fname') }} @endif {{-- Last Name --}} @if ($errors->has('lname')) {{ $errors->first('lname') }} @endif Gender* user->gender ? ($patient->user->gender == 'male' ? 'checked' : '') : '' }} required> Male user->gender ? ($patient->user->gender == 'female' ? 'checked' : '') : '' }}> Female user->gender ? ($patient->user->gender == 'Prefer not to respond' ? 'checked' : '') : '' }}> Prefer not to respond @if ($errors->has('gender')) {{ $errors->first('gender') }} @endif Ethnicity* Select Ethnicity user->ethnicity ? ($patient->user->ethnicity == 'AfricanAmerican' ? 'selected' : '') : '' }}> African American user->ethnicity ? ($patient->user->ethnicity == 'Asian' ? 'selected' : '') : '' }}> Asian user->ethnicity ? ($patient->user->ethnicity == 'Caucasian' ? 'selected' : '') : '' }}> Caucasian user->ethnicity ? ($patient->user->ethnicity == 'Hispanic' ? 'selected' : '') : '' }}> Hispanic user->ethnicity ? ($patient->user->ethnicity == 'Other' ? 'selected' : '') : '' }}> Other @if ($errors->has('ethnicity')) {{ $errors->first('ethnicity') }} @endif Date Of Birth * @if ($errors->has('dob')) {{ $errors->first('dob') }} @endif Email* @if ($errors->has('email')) {{ $errors->first('email') }} @endif Phone* @if ($errors->has('phone')) {{ $errors->first('phone') }} @endif Contact Name* Home Address* @if ($errors->has('address_one')) {{ $errors->first('address_one') }} @endif @if ($errors->has('address_two')) {{ $errors->first('address_two') }} @endif City* @if ($errors->has('city')) {{ $errors->first('city') }} @endif State* {{-- State --}} Select State @foreach ($states as $state) user->state) == $state->name ? 'selected' : '' }}> {{ $state->name }} @endforeach Zip Code* @if ($errors->has('zipcode')) {{ $errors->first('zipcode') }} @endif {{-- Are you 18 or older?* Yes No --}} {{-- Do you have Health Insurance* Yes No --}} Insurance Type {{-- --}} Select user->insurance_type == 'self_pay' ? 'selected' : '' }}>Self pay user->insurance_type == 'medicare' ? 'selected' : '' }}> Medicare user->insurance_type == 'medicaid' ? 'selected' : '' }}> Medicaid user->insurance_type == 'other_insurance' ? 'selected' : '' }}> Other Insurance user->insurance_type == 'commercial' ? 'selected' : '' }}> Commercial user->insurance_type == 'no_insurance' ? 'selected' : '' }}>No Insurance(Hrsa) @if ($errors->has('insurance_type')) {{ $errors->first('insurance_type') }} @endif Policy Number @if ($errors->has('policy_id')) {{ $errors->first('policy_id') }} @endif Group Number @if ($errors->has('group_id')) {{ $errors->first('group_id') }} @endif @if (!$patient->documents->isEmpty()) Documents @foreach ($patient->documents as $document) @endforeach @endif Update @endsection @push('scripts') @endpush