@extends('master')

<script type="text/javascript">
	$(document).foundation();
</script>

@section('content')

	<div class="row">
      	<div class="large-12 columns">
        	<h1>Lab Registration</h1>
      	</div>
    </div>

    <div class="row">
        <div class="small-12 medium-6 large-6 columns">
            <h4>Place Holder</h4>
        </div>
    </div>

    <div class="row">

    	<form action="{{{ URL::to('lab') }}}" method="post" data-abide>

			<div class="small-12 medium-12 large-12 columns">

				<div class="row">
	                <div class="small-12 medium-12 large-12 columns">
	                  <label>Lab Name</label>
	                  <input type="text" id="lab_name" name="lab_name" placeholder="" required />
	                  <small class="error" data-error-message>Lab Name is required.</small>
	                </div>
	            </div>

	            <div class="row">
	                <div class="small-12 medium-12 large-12 columns">
	                  <label>Description</label>
	                  <input type="text" id="description" name="description" placeholder="" required />
	                  <small class="error" data-error-message>Description is required.</small>
	                </div>
	            </div>

	            <div class="row">
	            	<div class="small-12 medium-4 large-4 columns">
	            		<label>HL7 version</label>
	            		<input type="text" id="HL7_version" name="HL7_version" placeholder="" required />
	                	<small class="error" data-error-message>HL7 version is required.</small>
	            	</div>
	            	<div class="small-12 medium-8 large-8 columns">
	            		<label>URL</label>
	            		<input type="text" id="url" name="url" placeholder="" required />
	                	<small class="error" data-error-message>URL is required.</small>
	            	</div>
	            </div>

	            <div class="row">
	                <div class="small-12 medium-12 large-12 columns">
	                  <label>Email</label>
	                  <input type="email" id="lab_email" name="lab_email" placeholder="" required />
	                  <small class="error" data-error-message>Email is required.</small>
	                </div>
	            </div>

	            <div class="row">
	                <div class="small-12 medium-12 large-12 columns">
	                  <label>Preferred</label>
	                  <input type="text" id="preferred" name="preferred" placeholder="" required />
	                  <small class="error" data-error-message>Preferred is required.</small>
	                </div>
	            </div>

	             <div class="row">
	            	
	            	<div class="small-12 large-12 columns">
	            		<hr>
	            		<h4>Hl7 Available Segments</h4>

	            		@foreach($hl7AvailableSegments as $key => $segment)

	            			@if($segment == 'MSA')
                                    <input type="hidden" name="{{$segment}}" value="{{$segment}}" /> 
                            @else
	            			
								<label>
									{{{$segment}}} 
									<input type="checkbox" name="{{{$segment}}}" value="{{{$segment}}}" {{{ ($segment == 'MSH')? 'checked onclick="return false"' : ''}}} >
								</label>
								
							@endif
	            										
	            		@endforeach
	            		
	            	</div>
	         
	            </div>


	            <div class="row">
	                <div class="small-6 medium-6 large-6 columns">
	                  <button class="expand">Save</button>
	                </div>
	                <div class="small-6 medium-6 large-6 end columns">
	                  <a href="{{{ URL::to('lab') }}}" class="button expand">Cancel</a>
	                </div>
	            </div>

			</div>

		</form>

	</div>


@stop