@extends('themes.frontend.layouts.app')
@section('flatpickr') @stop
@section('validate') @stop

@if (isset($dataArr['meta_title']))
	@section('page-title'){{ $dataArr['meta_title'] }}@stop
@else
	@section('page-title'){{ $dataArr['title'] }}@stop
@endif
@if (isset($dataArr['meta_key']))
	@section('meta-keywords'){{ $dataArr['meta_key'] }}@stop
@endif
@if (isset($dataArr['meta_descp']))
	@section('meta-description'){{ $dataArr['meta_descp'] }}@stop
@endif
@if (isset($dataArr['image_path']))
	@section('meta-image'){{ $dataArr['image_path'] }}@stop
@endif
@if ($dataArr['full_url'])
	@section('cur-url'){{ $dataArr['full_url'] }}@stop
@endif

@push('styles')
@if(isset($dataArr['custom_fields']['textarea_4']) && $dataArr['custom_fields']['textarea_4'] && $dataArr['custom_fields']['textarea_4']['value'])
<!--====== START: CUSTOM PAGE CSS from backed the Page ======-->
<style scoped>
	{!! $dataArr['custom_fields']['textarea_4']['value'] !!}
</style>
<!--====== END: CUSTOM PAGE CSS from backed the Page ======-->
@endif
@endpush

@section('content')
<!--====== BANNER PART START ======-->
@include('themes.frontend.includes.breadcrumb',['titleClass'=>'text-white'])
<!--====== BANNER PART ENDS ======-->

<!--==================================================-->
<!-----Start contact Section Style Seven ----->
<!--===================================================-->
@if (isset($dataArr['custom_fields']['editor_1']))
    {!!  app(App\Services\ShortcodeProcessor::class)->process($dataArr['custom_fields']['editor_1']['value']) !!}
@endif

<section class="appoinment-form  appointment-page pt-pb-130 ">
    <div class="container">
      	<div class="row">
        	<div class="col-xl-12">
          		<div class="appoinment-box">
					<center>
						<h1>ALLISTON PHYSIOTHERAPY &amp; SPORTS REHABILITATION</h1>
						<h4>27 Victoria St. East, Alliston, On L9R1T9<br>Tel 705-434-0645 or 705-435-5153 Fax 705-435-5754</h4>
						<p>AUTHORIZATION FOR RELEASE OF CLIENT INFORMATION</p>
					</center>
					@if(session('success'))
						<div class="alert alert-success">{{ session('success') }}</div>
					@endif
                	<div class="row">
    					<form action="{{ url('authorization-process') }}" name="new_patient" id="new_patient" method="post" novalidate="novalidate">
							@csrf
                			<div class="pq-appointment">
								<div class="row">
									<div class="col-lg-6">Patient Name <span class="required text-danger">*</span>		
										<input class="form-control pq-bg-white paitent-name-field" id="" name="patient_name" required="required" type="text"   placeholder="Name" value="{{ old('patient_name') }}"  autocomplete="off">
										@error('patient_name') <span class="text-danger">{{ $message }}</span> @enderror
									</div>                
                					<div class="col-lg-6  ">Date Of Birth <span class="required text-danger">*</span>		
										<input class="form-control pq-bg-white paitent-dob-field date_empty" id="" name="dob" required="required" type="date"   placeholder="Date Of Birth" value="{{ old('dob') }}"  autocomplete="off">
										@error('dob') <span class="text-danger">{{ $message }}</span> @enderror
									</div>
									<div class="col-lg-12">
										<h6 class="text-white">PART A - Pertaining to Extended Health Care Centre</h6>
										<p>I, the undersigned, hereby authorize representatives of Alliston Physiotherapy and Sports Rehabilitation to be permitted to review related records, progress reports and to discuss pertinent data with professionals involved in my rehabilitation process.<br>Collection, use, disclosure, security and retention of information is subject to and in compliance with the Personal Information Protection and Electronic Documents Act (please see a copy of our privacy policy) I agree that a photocopy of this authorization be accepted if necessary</p>
									</div>
									<div class="col-lg-6  ">Signature <span class="required text-danger">*</span>		
										<input class="form-control pq-bg-white paitent-name-field" id="" name="partA_signature" required="required" type="text"   placeholder="" value="{{ old('partA_signature') }}"  autocomplete="off">
										@error('partA_signature') <span class="text-danger">{{ $message }}</span> @enderror
									</div> 
									<div class="col-lg-6  ">Witness <span class="required text-danger">*</span>		
										<input class="form-control pq-bg-white paitent-name-field" id="" name="partA_witness" required="required" type="text"   placeholder="" value="{{ old('partA_witness') }}"  autocomplete="off">
										@error('partA_witness') <span class="text-danger">{{ $message }}</span> @enderror
									</div> 
									<div class="col-lg-6  ">Date <span class="required text-danger">*</span>		
										<input class="form-control pq-bg-white paitent-dob-field date_empty" id="" name="partA_date1" required="required" type="date"   placeholder=""  value="{{ old('partA_date1') }}" autocomplete="off">
										@error('partA_date1') <span class="text-danger">{{ $message }}</span> @enderror
									</div>
									<div class="col-lg-6  ">Date <span class="required text-danger">*</span>		
										<input class="form-control pq-bg-white paitent-dob-field date_empty" id="" name="partA_date2" required="required" type="date"   placeholder="" value="{{ old('partA_date2') }}"  autocomplete="off">
										@error('partA_date2') <span class="text-danger">{{ $message }}</span> @enderror
									</div>
									<div class="col-lg-12">
										<h6 class="text-white">PART B - Pertaining to Clients with Work Related and/or Motor Vehicle Injuries</h6>
										<p>I hereby authorize Alliston Physiotherapy and Sports Rehabilitation to release pertinent functional and medical information to my Doctor(s), Representatives of the Workplace Safety &amp; Insurance Board / Representatives of Insurance Provider / Lawyer or Representatives / other Health Care Providers. In regards to Workplace Safety &amp; Insurance Board claims, the undersigned hereby consents &amp; authorize you to provide to my employer, periodic progress reports in the course of my treatment at Alliston Physiotherapy &amp; Sports Rehabilitation. If required to provide progress reports, you are authorized to make reference to information that you may have in your possession which relates to my treatment. Collection, use, disclosure, security and retention of information is subject to and in compliance with the Personal Information Protection and Electronic Documents Act (please see a copy of our privacy policy) I agree that a photocopy of this authorization be accepted if necessary.</p>
									</div>
									<div class="col-lg-6  ">Signature <span class="required text-danger">*</span>		
										<input class="form-control pq-bg-white paitent-name-field" id="" name="partB_signature" required="required" type="text"   placeholder="" value="{{ old('partB_signature') }}"  autocomplete="off">
										@error('partB_signature') <span class="text-danger">{{ $message }}</span> @enderror
									</div> 
									<div class="col-lg-6  ">Witness <span class="required text-danger">*</span>		
										<input class="form-control pq-bg-white paitent-name-field" id="" name="partB_witness" required="required" type="text"   placeholder="" value="{{ old('partB_witness') }}"  autocomplete="off">
										@error('partB_witness') <span class="text-danger">{{ $message }}</span> @enderror
									</div> 
									<div class="col-lg-6  ">Date <span class="required text-danger">*</span>		
										<input class="form-control pq-bg-white paitent-dob-field date_empty" id="" name="partB_date1" required="required" type="date"   placeholder="" value="{{ old('partB_date1') }}"  autocomplete="off">
										@error('partB_date1') <span class="text-danger">{{ $message }}</span> @enderror
									</div>
									<div class="col-lg-6  ">Date <span class="required text-danger">*</span>		
										<input class="form-control pq-bg-white paitent-dob-field date_empty" id="" name="partB_date2" required="required" type="date"   placeholder="" value="{{ old('partB_date2') }}"  autocomplete="off">
										@error('partB_date2') <span class="text-danger">{{ $message }}</span> @enderror
									</div> 
									<div class="col-lg-12">
										<input type="checkbox" name="tests[]" value="xray"
											{{ in_array('xray', old('tests', [])) ? 'checked' : '' }}> X-Ray

										<input type="checkbox" name="tests[]" value="ct"
											{{ in_array('ct', old('tests', [])) ? 'checked' : '' }}> CT

										<input type="checkbox" name="tests[]" value="mri"
											{{ in_array('mri', old('tests', [])) ? 'checked' : '' }}> MRI

										<input type="checkbox" name="tests[]" value="ultrasound"
											{{ in_array('ultrasound', old('tests', [])) ? 'checked' : '' }}> Ultrasound
									</div>
								</div>
								<div class="col-lg-12  ">
									<center>
										<div class="quote_btn pb-4 ">
											<div class="pq-button-block">
												<button type="submit" class="pq-button-text me-0" id="send_new_patient" name="send_new_patient">Submit Now</button>
											</div>
										</div>
									</center>
								</div>
							</div>
						</form>
						<!-- END: FORM -->
					</div>
				</div>
			</div>
		</div>
	</div>
</section>
@stop