@extends('master')

<script type="text/javascript">
	$(document).foundation();
</script>
@section('content')
    <div class="row">
        <div class="large-12 columns">
            <div class="row">
                <div class="small-12 medium-12 large-12 columns">
                    <h4>Provider Details</h4>
                </div>
            </div>

            <div class="row">
                <div class="small-6 medium-6 large-6 columns">
                    <h5>{{{ $providerData->fname . " " . $providerData->lname }}}</h5>
                </div>
            </div>

            <div class="row">
                <div class="small-12 medium-12 large-12 columns">
                    <p>This screen is for editing provider preferences. </p>
                </div>
            </div>
        </div>
    </div>


    <div class="row">

    	<form action="{{{ URL::to('provider/' . $providerData->id ) }}}" method="post" data-abide>
    		<input name="_method" type="hidden" value="PUT">

			<div class="small-12 medium-9 large-9  columns">
        
	        <!-- <form> -->
	        <div class="row">
                <div class="large-12 columns">
                  <h5>Provider Information</h5> 
                </div>
            </div>
	        <input hidden id="provider_ID" name="provider_ID" value="{{{$providerData->id}}}" />

		         <div class="row">
	                <div class="small-12 medium-6 large-6 columns">
	                  <label>First Name</label>
	                  <input type="text" id="first_name" name="first_name" placeholder="" required pattern="[a-zA-Z]+" value="{{{$providerData->fname}}}" />
	                  <small class="error" data-error-message>First Name is required and must be a string.</small>
	                </div>
	                <div class="small-6 medium-3 large-3 columns end ">
	                  <label>Middle Name</label>
	                  <input type="text" id="middle_name" name="middle_name" placeholder="" pattern="[a-zA-Z]+" value="{{{$providerData->mname}}}" />
	                  <small class="error" data-error-message>Must be a string.</small>
	                </div>
	             </div>
	             <div class="row">
	                <div class="small-12 medium-9 large-9 columns end">
	                  <label>Last Name</label>
	                  <input type="text" id="last_name" name="last_name" placeholder="" required pattern="[a-zA-Z]+" value="{{{$providerData->lname}}}" />
	                  <small class="error" data-error-message>Last Name is required and must be a string.</small>
	                </div>
	            </div>

	            <div class="row">
	            	<div class="small-12 medium-9 large-9 columns end">
	            		<label>Email / Username</label>
	            		<input hidden id="provider_email" name="provider_email" placeholder="" required value="{{{$providerData->username}}}" readonly/>
	            		<strong>{{{$providerData->username}}}</strong>
	            	</div>
	            </div>
	            <hr>
	             <div class="row">
	                <div class="large-12 columns">
	                  <h5>User Role</h5> 
	                </div>
	            </div>
	            <div class="row">
	            	<div class="small-12 medium-4 large-4 columns">
	            		<input hidden id="user_role" name="user_role" placeholder="" required value="{{{$providerRole}}}" readonly/>
	            		<strong>{{{$providerRole}}}</strong>	
	            	</div>
	            </div>
	            <hr>

		        <div class="row">
	                <div class="large-12 columns">
	                  <h5>Address</h5>
	                  <p>Practice office address</p> 
	                </div>
	            </div>

	            <div id="address">
	              <div class="row">
	                  <div class="small-12 medium-9 large-9 columns">
	                    <label>Address 1</label>
	                    <input type="text" id="address1" name="address1" placeholder="" required  value="{{{$providerData->street}}}" />
	                    <small class="error" data-error-message>Street is required and must be a string.</small>
	                  </div>
	              </div>
	              <div class="row">
	                <div class="small-12 medium-9 large-9 columns">
	                    <label>Address 2</label>
	                    <input type="text" id="address2" name="address2" placeholder="" required  value="{{{$providerData->streetb}}}" />
	                    <small class="error" data-error-message>Street is required and must be a string.</small>
	                  </div>
	              </div>
	              <div class="row">
	                  <div class="small-12 medium-9 large-9 columns">
	                    <label>City</label>
	                    <input type="text" id="city" name="city" placeholder="" value="{{{$providerData->city}}}"  />
	                    <small class="error" data-error-message>Must be a string.</small>
	                  </div>
				   </div>
	               <div class="row">
	                  <div class="small-12 medium-5 large-5 columns">
	                    <label>State</label>
	                    <input type="text" id="state" name="state" placeholder="" value="{{{$providerData->state}}}" />
	                    <small class="error" data-error-message>Must be a string.</small>
	                  </div>
	                  <div class="small-12 medium-4 large-4 columns end">
	                    <label>Zipcode</label>
	                    <input type="text" id="postal_code" name="postal_code" placeholder="" required value="{{{$providerData->zip}}}" />
	                    <small class="error" data-error-message>Zipcode is required.</small>
	                  </div>
	                  
	                  <div class="large-12 columns">
	                    <hr>
	                  </div>
	              </div>
	            </div>

		        <div class="row">
	                <div class="small-12 medium-5 large-5 columns">
	                  <label>Phone</label>
	                  <input type="text" id="phone" name="phone" placeholder="" value="{{{$providerData->phone}}}"  />
	                </div>
	                <div class="small-12 medium-4 large-4 end columns">
	                  <label>Email</label>
	                  <input hidden id="email" name="email" required placeholder="" value="{{{$providerData->email}}}" />
	                  <strong>{{{ $providerData->email }}}</strong>
	                  <small class="error" data-error-message>Email is required with email format.</small>
	                </div>
	            </div>

		        <div class="row">
		            <div class="small-12 medium-5 large-5 columns">
			            <label>License</label>
			            <input hidden id="license" name="license" placeholder="" pattern="([A-Za-z]{1})[0-9]+" required value="{{{$providerData->state_license_number}}}" />
			            <strong>{{{$providerData->state_license_number}}}</strong>
			            <small class="error" data-error-message>License is required with one letter and numbers.</small>
		            </div>
		            <div class="small-12 medium-4 large-4 end columns">
			            
			            <label>
				        	Preferred Lab
				        	@if(isset($providerPreferedLab))
								(Actual - {{{$providerLab->name}}})
							@endif
				        </label>
				        <select id="preferred_lab" name="preferred_lab">
							@foreach($labs as $lab)
								<option value="{{{$lab->id}}}"> {{{$lab->name}}} </option>
							@endforeach
						</select>
		            </div>
		        </div>

		        <div class="row">
		            <div class="small-12 medium-4 large-4 end columns">
		                  <a href="{{{ URL::to('provider') }}}" class="button expand">Back</a>
		            </div>
		            <div class="small-12 medium-4 large-4 end columns">
		                  <button class="button expand">Update</button>
		            </div>
	            </div>
			</div>
      	</form>
    </div>

    
@stop