@php 
    $parent_or_guardian = $dataObj->parent_or_guardian ?? '';
    $fi_method_paymentArr = $fi_fin_matrArr = $mh_tickArr = [];
@endphp
<div class="row">

    {{-- Alert message start --}}
    @if(session()->has('alert'))
    <x-form.alert type="{{ session()->get('alert') }}" title="{{ session()->get('title') }}" message="{{ session()->get('message') }}" />
    @endif
    {{-- Alert message end --}}
                    
    @if ($errors->any())
    <div class="row mb-5">
        <div class="col-lg-12 alert">
            <ul>
                @foreach ($errors->all() as $error)
                <li class="alert alert-danger" role="alert" style="margin-bottom: 2px;">
                    {{ $error }}
                </li>
                @endforeach
            </ul>
        </div>
    </div>
    @endif

    <form action="{{ $route }}" name="new_patient" id="new_patient" method="post">
        {{ csrf_field() }}
        <x-form.field.hidden name="recaptcha_v3" id="recaptcha_v3" />
        <x-form.field.hidden name="page_ref" id="page_ref" value="{{ url()->full() }}" />
        <div class="pq-appointment">

            <!-- <div class="row">
                <x-form.frnt_group_lyt7v1_1 error="{{ $errors->first('new_patient_forms.name') }}" label="{{ __('enquiry.name_txt') }}" required=true>
                    <x-form.field.text2 id="new_patient_forms-name" name="new_patient_forms[name]" placeholder="{{ __('enquiry.name_txt') }}"  value="{{ old('new_patient_forms.name') ?? $dataObj->name ?? '' }}" class="form-control pq-bg-white paitent-name-field" required/>
                </x-form.frnt_group_lyt7v1_1>                
                <x-form.frnt_group_lyt7v1_1 error="{{ $errors->first('new_patient_forms.dob') }}" label="{{ __('enquiry.new_form.dob_txt') }}" required=true>
                    <x-form.field.text2 type="date" id="new_patient_forms-dob" name="new_patient_forms[dob]" placeholder="{{ __('enquiry.new_form.dob_txt') }}"  value="{{ old('new_patient_forms.dob') ?? $dataObj->dob ?? '' }}" class="form-control pq-bg-white paitent-dob-field date_empty" required/>
                </x-form.frnt_group_lyt7v1_1>

                <x-form.frnt_group_lyt7v1_1 error="{{ $errors->first('new_patient_forms.type_of_appointment') }}" label="{{ __('enquiry.new_form.type_of_appointment_txt') }}">
                    <x-form.field.textarea id="new_patient_forms-type_of_appointment" name="new_patient_forms[type_of_appointment]" placeholder="{{ __('enquiry.new_form.type_of_appointment_txt') }}"  value="{{ old('new_patient_forms.type_of_appointment') ?? $dataObj->type_of_appointment ?? '' }}" class="form-control pq-bg-white" />
                </x-form.frnt_group_lyt7v1_1>

                <x-form.frnt_group_lyt7v1_1 error="{{ $errors->first('new_patient_forms.phone_home') }}" label="{{ __('enquiry.new_form.phone_txt') }}">
                    <x-form.field.text2 id="new_patient_forms-phone_home" name="new_patient_forms[phone_home]" placeholder="{{ __('enquiry.new_form.phone_home_txt') }}"  value="{{ old('new_patient_forms.phone_home') ?? $dataObj->phone_home ?? '' }}" class="form-control pq-bg-white" />
                    <x-form.field.text2 id="new_patient_forms-phone_work" name="new_patient_forms[phone_work]" placeholder="{{ __('enquiry.new_form.phone_work_txt') }}"  value="{{ old('new_patient_forms.phone_work') ?? $dataObj->phone_work ?? '' }}" class="form-control pq-bg-white" />
                </x-form.frnt_group_lyt7v1_1>


                <x-form.frnt_group_lyt7v1_1 error="{{ $errors->first('new_patient_forms.doctor_name') }}" label="{{ __('enquiry.new_form.doctor_name_txt') }}">
                    <x-form.field.text2 id="new_patient_forms-doctor_name" name="new_patient_forms[doctor_name]" placeholder="{{ __('enquiry.new_form.doctor_name_txt') }}"  value="{{ old('new_patient_forms.doctor_name') ?? $dataObj->doctor_name ?? '' }}" class="form-control pq-bg-white" />
                </x-form.frnt_group_lyt7v1_1>

                <x-form.frnt_group_lyt7v1_1 error="{{ $errors->first('new_patient_forms.occupation') }}" label="{{ __('enquiry.new_form.occupation_txt') }}">
                    <x-form.field.text2 id="new_patient_forms-occupation" name="new_patient_forms[occupation]" placeholder="{{ __('enquiry.new_form.occupation_txt') }}"  value="{{ old('new_patient_forms.occupation') ?? $dataObj->occupation ?? '' }}" class="form-control pq-bg-white" />
                </x-form.frnt_group_lyt7v1_1>

                <x-form.frnt_group_lyt7v1_1 error="{{ $errors->first('new_patient_forms.address') }}" label="{{ __('enquiry.new_form.address_txt') }}">
                    <x-form.field.text2 id="new_patient_forms-address" name="new_patient_forms[address]" placeholder="{{ __('enquiry.new_form.address_txt') }}"  value="{{ old('new_patient_forms.address') ?? $dataObj->address ?? '' }}" class="form-control pq-bg-white" />
                </x-form.frnt_group_lyt7v1_1>

                <x-form.frnt_group_lyt7v1_1 error="{{ $errors->first('new_patient_forms.allergies') }}" label="{{ __('enquiry.new_form.allergies_txt') }}">
                    <x-form.field.text2 id="new_patient_forms-allergies" name="new_patient_forms[allergies]" placeholder="{{ __('enquiry.new_form.allergies_txt') }}"  value="{{ old('new_patient_forms.allergies') ?? $dataObj->allergies ?? '' }}" class="form-control pq-bg-white" />
                </x-form.frnt_group_lyt7v1_1>

                <x-form.frnt_group_lyt7v1_1 error="{{ $errors->first('new_patient_forms.phone') }}" label="{{ __('enquiry.new_form.phone_txt') }}" required=true>
                    <x-form.field.text2 id="new_patient_forms-phone" name="new_patient_forms[phone]" placeholder="{{ __('enquiry.new_form.phone_txt') }}"  value="{{ old('new_patient_forms.phone') ?? $dataObj->phone ?? '' }}" class="form-control pq-bg-white" required/>
                </x-form.frnt_group_lyt7v1_1>

                <x-form.frnt_group_lyt7v1_1 error="{{ $errors->first('new_patient_forms.email') }}" label="{{ __('enquiry.new_form.email_txt') }}" required=true>
                    <x-form.field.text2 type="email" id="new_patient_forms-email" name="new_patient_forms[email]" placeholder="{{ __('enquiry.new_form.email_txt') }}"  value="{{ old('new_patient_forms.email') ?? $dataObj->email ?? '' }}" class="form-control pq-bg-white" required/>
                </x-form.frnt_group_lyt7v1_1>

                <x-form.frnt_group_lyt7v1_1 error="{{ $errors->first('new_patient_forms.emergency_contact_no') }}" label="{{ __('enquiry.new_form.emergency_contact_no_txt') }}">
                    <x-form.field.text2 id="new_patient_forms-emergency_contact_no" name="new_patient_forms[emergency_contact_no]" placeholder="{{ __('enquiry.new_form.emergency_contact_no_txt') }}"  value="{{ old('new_patient_forms.emergency_contact_no') ?? $dataObj->emergency_contact_no ?? '' }}" class="form-control pq-bg-white" />
                </x-form.frnt_group_lyt7v1_1>
                <x-form.frnt_group_lyt7v1_1 error="{{ $errors->first('new_patient_forms.health_care_no') }}" label="{{ __('enquiry.new_form.health_care_no_txt') }}">
                    <x-form.field.text2 id="new_patient_forms-health_care_no" name="new_patient_forms[health_care_no]" placeholder="{{ __('enquiry.new_form.health_care_no_txt') }}"  value="{{ old('new_patient_forms.health_care_no') ?? $dataObj->health_care_no ?? '' }}" class="form-control pq-bg-white" />
                </x-form.frnt_group_lyt7v1_1>

                <x-form.frnt_group_lyt7v1_1 default_class="col-lg-12" error="{{ $errors->first('new_patient_forms.physiotherapy_reason') }}" label="{{ __('enquiry.new_form.physiotherapy_reason_txt') }}">
                    <x-form.field.text2 id="new_patient_forms-physiotherapy_reason" name="new_patient_forms[physiotherapy_reason]" placeholder="{{ __('enquiry.new_form.physiotherapy_reason_txt') }}"  value="{{ old('new_patient_forms.physiotherapy_reason') ?? $dataObj->physiotherapy_reason ?? '' }}" class="form-control pq-bg-white" />
                </x-form.frnt_group_lyt7v1_1>

                <x-form.frnt_group_lyt7v1_1 error="{{ $errors->first('new_patient_forms.how_long_condition_existed') }}" label="{{ __('enquiry.new_form.how_long_condition_existed_txt') }}">
                    <x-form.field.text2 id="new_patient_forms-how_long_condition_existed" name="new_patient_forms[how_long_condition_existed]" placeholder="{{ __('enquiry.new_form.how_long_condition_existed_txt') }}"  value="{{ old('new_patient_forms.how_long_condition_existed') ?? $dataObj->how_long_condition_existed ?? '' }}" class="form-control pq-bg-white" />
                </x-form.frnt_group_lyt7v1_1>
                <x-form.frnt_group_lyt7v1_1 error="{{ $errors->first('new_patient_forms.health') }}" label="{{ __('enquiry.new_form.health_txt') }}">
                    <x-form.field.text2 id="new_patient_forms-health" name="new_patient_forms[health]" placeholder="{{ __('enquiry.new_form.health_txt') }}"  value="{{ old('new_patient_forms.health') ?? $dataObj->health ?? '' }}" class="form-control pq-bg-white" />
                </x-form.frnt_group_lyt7v1_1>

                <x-form.frnt_group_lyt7v1_1 error="{{ $errors->first('new_patient_forms.referred_physiotherapy') }}" label="{{ __('enquiry.new_form.referred_physiotherapy_txt') }}">
                    <input type="radio" value="doctor" id="new_patient_forms-referred_physiotherapy-1" name="new_patient_forms[referred_physiotherapy]" @if((old('new_patient_forms.referred_physiotherapy') =='doctor') || (!empty($dataObj->referred_physiotherapy) && $dataObj->referred_physiotherapy =='doctor')) checked @endif>&nbsp;Doctor &nbsp;&nbsp;&nbsp;&nbsp;
                    <span class="form-control-option">
                        <input type="radio" value="other" id="new_patient_forms-referred_physiotherapy-2" name="new_patient_forms[referred_physiotherapy]" @if((old('new_patient_forms.referred_physiotherapy') =='other') || (!empty($dataObj->referred_physiotherapy) && $dataObj->referred_physiotherapy =='other')) checked @endif>&nbsp;Other
                    </span>
                </x-form.frnt_group_lyt7v1_1>
                <x-form.frnt_group_lyt7v1_1 error="{{ $errors->first('new_patient_forms.physiotherapy_other') }}">
                    <x-form.field.text2 id="new_patient_forms-physiotherapy_other" name="new_patient_forms[physiotherapy_other]" placeholder="{{ __('enquiry.new_form.physiotherapy_other_txt') }}"  value="{{ old('new_patient_forms.physiotherapy_other') ?? $dataObj->physiotherapy_other ?? '' }}" class="form-control pq-bg-white" />
                </x-form.frnt_group_lyt7v1_1>

                <x-form.frnt_group_lyt7v1_1 default_class="col-lg-12" error="{{ $errors->first('new_patient_forms.has_past_physiotherapy') }}" label="{{ __('enquiry.new_form.has_past_physiotherapy_txt') }}">
                    <input type="radio" value="1" id="new_patient_forms-has_past_physiotherapy-1" name="new_patient_forms[has_past_physiotherapy]" @if((old('new_patient_forms.has_past_physiotherapy') =='1') || (!empty($dataObj->has_past_physiotherapy) && $dataObj->has_past_physiotherapy =='1')) checked @endif>
                    &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                    <span class="form-control-option">
                        <input type="radio" value="2" id="new_patient_forms-has_past_physiotherapy-2" name="new_patient_forms[has_past_physiotherapy]" @if((old('new_patient_forms.has_past_physiotherapy') =='2') || (!empty($dataObj->has_past_physiotherapy) && $dataObj->has_past_physiotherapy =='2')) checked @endif>
                        &nbsp;No
                    </span>
                </x-form.frnt_group_lyt7v1_1>

                <x-form.frnt_group_lyt7v1_1 error="{{ $errors->first('new_patient_forms.current_medications_name') }}">
                    <h4>Current Medications</h4>
                    Name
                    <x-form.field.text2 id="new_patient_forms-current_medications_name" name="new_patient_forms[current_medications_name]" placeholder="{{ __('enquiry.new_form.current_medications_name_txt') }}"  value="{{ old('new_patient_forms.current_medications_name') ?? $dataObj->current_medications_name ?? '' }}" class="form-control pq-bg-white" /><br>
                    Condition
                    <x-form.field.text2 id="new_patient_forms-current_medications_condition" name="new_patient_forms[current_medications_condition]" placeholder="{{ __('enquiry.new_form.current_medications_condition_txt') }}"  value="{{ old('new_patient_forms.current_medications_condition') ?? $dataObj->current_medications_condition ?? '' }}" class="form-control pq-bg-white" />
                </x-form.frnt_group_lyt7v1_1>
                <x-form.frnt_group_lyt7v1_1 error="{{ $errors->first('new_patient_forms.current_medications_notes') }}" label="{{ __('enquiry.new_form.current_medications_notes_txt') }}">
                    <h4>Other medical conditions to note</h4> (ie. pins, wires, plates, artificial joints, canes..)
                    <x-form.field.textarea id="new_patient_forms-current_medications_notes" name="new_patient_forms[current_medications_notes]" placeholder="{{ __('enquiry.new_form.current_medications_notes_txt') }}"  value="{{ old('new_patient_forms.current_medications_notes') ?? $dataObj->current_medications_notes ?? '' }}" class="form-control pq-bg-white" />
                </x-form.frnt_group_lyt7v1_1>

                
                <div class="col-md-6">
                    <h4>Injury</h4>
                    <div class="row">
                        <x-form.frnt_group_lyt7v1_1 error="{{ $errors->first('new_patient_forms.injury_type') }}">
                            Type
                            <x-form.field.text2 id="new_patient_forms-injury_type" name="new_patient_forms[injury_type]" placeholder="{{ __('enquiry.new_form.injury_type_txt') }}"  value="{{ old('new_patient_forms.injury_type') ?? $dataObj->injury_type ?? '' }}" class="form-control pq-bg-white" />
                        </x-form.frnt_group_lyt7v1_1>
                        <x-form.frnt_group_lyt7v1_1 error="{{ $errors->first('injury_date') }}">
                            Date
                            <x-form.field.text2 type="date" id="new_patient_forms-injury_date" name="new_patient_forms[injury_date]" placeholder="{{ __('enquiry.new_form.injury_date_txt') }}"  value="{{ old('new_patient_forms.injury_date') ?? $dataObj->injury_date ?? '' }}" class="form-control pq-bg-white date_empty" />
                        </x-form.frnt_group_lyt7v1_1>
                    </div>
                </div>                
                <div class="col-md-6">
                    <h4>Surgeries</h4>
                    <div class="row">
                        <x-form.frnt_group_lyt7v1_1 error="{{ $errors->first('new_patient_forms.surgeries_type') }}">
                            Type
                            <x-form.field.text2 id="new_patient_forms-surgeries_type" name="new_patient_forms[surgeries_type]" placeholder="{{ __('enquiry.new_form.surgeries_type_txt') }}"  value="{{ old('new_patient_forms.surgeries_type') ?? $dataObj->surgeries_type ?? '' }}" class="form-control pq-bg-white" />
                        </x-form.frnt_group_lyt7v1_1>
                        <x-form.frnt_group_lyt7v1_1 error="{{ $errors->first('new_patient_forms.surgeries_date') }}">
                            Date
                            <x-form.field.text2 type="date" id="new_patient_forms-surgeries_date" name="new_patient_forms[surgeries_date]" placeholder="{{ __('enquiry.new_form.surgeries_date_txt') }}"  value="{{ old('new_patient_forms.surgeries_date') ?? $dataObj->surgeries_date ?? '' }}" class="form-control pq-bg-white date_empty" />
                        </x-form.frnt_group_lyt7v1_1>
                    </div>
                </div>

                <x-form.frnt_group_lyt7v1_1 default_class="col-lg-12" error="{{ $errors->first('new_patient_forms.treatment_from_professional') }}" label="{{ __('enquiry.new_form.treatment_from_professional_txt') }}">
                    <x-form.field.text2 id="new_patient_forms-treatment_from_professional" name="new_patient_forms[treatment_from_professional]" placeholder="{{ __('enquiry.new_form.treatment_from_professional_txt') }}"  value="{{ old('new_patient_forms.treatment_from_professional') ?? $dataObj->treatment_from_professional ?? '' }}" class="form-control pq-bg-white" />
                </x-form.frnt_group_lyt7v1_1>

            </div> -->

            {{-- BASIC INFORMATION --}}
            @include('themes.frontend.pages.partials.section.__new_patient_basic',[])
            <br><br><!--Step3 -->
            <hr><br><br>

            <!-- <div class="row">
                <x-form.frnt_group_lyt7v1_1 default_class="col-lg-12" bold_label=true error="{{ $errors->first('new_patient_problems.has_heart_problems') }}" label="{{ __('enquiry.new_form.has_heart_problems_txt') }}">
                        <input type="radio" value="1" id="new_patient_problems-has_heart_problems-1" name="new_patient_problems[has_heart_problems]" @if((old('new_patient_problems.has_heart_problems') =='1') || (!empty($new_patient_problems->has_heart_problems) && $new_patient_problems->has_heart_problems =='1')) checked @endif>
                        &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                        </span><span class="form-control-option">
                        <input type="radio" value="2" id="new_patient_problems-has_heart_problems-2" name="new_patient_problems[has_heart_problems]" @if((old('new_patient_problems.has_heart_problems') =='2') || (!empty($new_patient_problems->has_heart_problems) && $new_patient_problems->has_heart_problems =='2')) checked @endif>
                        &nbsp;No
                </x-form.frnt_group_lyt7v1_1>
                <x-form.frnt_group_lyt7v1_1 default_class="col-lg-12" bold_label=true error="{{ $errors->first('new_patient_problems.has_thyroid_problems') }}" label="{{ __('enquiry.new_form.has_thyroid_problems_txt') }}">
                        <input type="radio" value="1" id="new_patient_problems-has_thyroid_problems-1" name="new_patient_problems[has_thyroid_problems]" @if((old('new_patient_problems.has_thyroid_problems') =='1') || (!empty($new_patient_problems->has_thyroid_problems) && $new_patient_problems->has_thyroid_problems =='1')) checked @endif>
                        &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                        </span><span class="form-control-option">
                        <input type="radio" value="2" id="new_patient_problems-has_thyroid_problems-2" name="new_patient_problems[has_thyroid_problems]" @if((old('new_patient_problems.has_thyroid_problems') =='2') || (!empty($new_patient_problems->has_thyroid_problems) && $new_patient_problems->has_thyroid_problems =='2')) checked @endif>
                        &nbsp;No
                </x-form.frnt_group_lyt7v1_1>
                <x-form.frnt_group_lyt7v1_1 default_class="col-lg-12" bold_label=true error="{{ $errors->first('new_patient_problems.has_high_or_low_blood_pressure') }}" label="{{ __('enquiry.new_form.has_high_or_low_blood_pressure_txt') }}">
                        <input type="radio" value="1" id="new_patient_problems-has_high_or_low_blood_pressure-1" name="new_patient_problems[has_high_or_low_blood_pressure]" @if((old('new_patient_problems.has_high_or_low_blood_pressure') =='1') || (!empty($new_patient_problems->has_high_or_low_blood_pressure) && $new_patient_problems->has_high_or_low_blood_pressure =='1')) checked @endif>
                        &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                        </span><span class="form-control-option">
                        <input type="radio" value="2" id="new_patient_problems-has_high_or_low_blood_pressure-2" name="new_patient_problems[has_high_or_low_blood_pressure]" @if((old('new_patient_problems.has_high_or_low_blood_pressure') =='2') || (!empty($new_patient_problems->has_high_or_low_blood_pressure) && $new_patient_problems->has_high_or_low_blood_pressure =='2')) checked @endif>
                        &nbsp;No
                </x-form.frnt_group_lyt7v1_1>
                <x-form.frnt_group_lyt7v1_1 default_class="col-lg-12" bold_label=true error="{{ $errors->first('new_patient_problems.has_taking_any_medications') }}" label="{{ __('enquiry.new_form.has_taking_any_medications_txt') }}">
                        <input type="radio" value="1" id="new_patient_problems-has_taking_any_medications-1" name="new_patient_problems[has_taking_any_medications]" @if((old('new_patient_problems.has_taking_any_medications') =='1') || (!empty($new_patient_problems->has_taking_any_medications) && $new_patient_problems->has_taking_any_medications =='1')) checked @endif>
                        &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                        </span><span class="form-control-option">
                        <input type="radio" value="2" id="new_patient_problems-has_taking_any_medications-2" name="new_patient_problems[has_taking_any_medications]" @if((old('new_patient_problems.has_taking_any_medications') =='2') || (!empty($new_patient_problems->has_taking_any_medications) && $new_patient_problems->has_taking_any_medications =='2')) checked @endif>
                        &nbsp;No
                </x-form.frnt_group_lyt7v1_1>
                <x-form.frnt_group_lyt7v1_1 default_class="col-lg-12" error="{{ $errors->first('new_patient_problems.taking_any_medication_list') }}" >
                    <x-form.field.text2 id="new_patient_problems-taking_any_medication_list" name="new_patient_problems[taking_any_medication_list]" placeholder="{{ __('enquiry.new_form.taking_any_medication_list_txt') }}"  value="{{ old('new_patient_problems.taking_any_medication_list') ?? $new_patient_problems->taking_any_medication_list ?? '' }}" class="form-control pq-bg-white" />
                </x-form.frnt_group_lyt7v1_1>


                <x-form.frnt_group_lyt7v1_1 default_class="col-lg-12" bold_label=true error="{{ $errors->first('new_patient_problems.has_diagnosed_with_arthritis') }}" label="{{ __('enquiry.new_form.has_diagnosed_with_arthritis_txt') }}">
                        <input type="radio" value="1" id="new_patient_problems-has_diagnosed_with_arthritis-1" name="new_patient_problems[has_diagnosed_with_arthritis]" @if((old('new_patient_problems.has_diagnosed_with_arthritis') =='1') || (!empty($new_patient_problems->has_diagnosed_with_arthritis) && $new_patient_problems->has_diagnosed_with_arthritis =='1')) checked @endif>
                        &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                        </span><span class="form-control-option">
                        <input type="radio" value="2" id="new_patient_problems-has_diagnosed_with_arthritis-2" name="new_patient_problems[has_diagnosed_with_arthritis]" @if((old('new_patient_problems.has_diagnosed_with_arthritis') =='2') || (!empty($new_patient_problems->has_diagnosed_with_arthritis) && $new_patient_problems->has_diagnosed_with_arthritis =='2')) checked @endif>
                        &nbsp;No
                </x-form.frnt_group_lyt7v1_1>

                <x-form.frnt_group_lyt7v1_1 default_class="col-lg-12" bold_label=true error="{{ $errors->first('new_patient_problems.has_diabetes') }}" label="{{ __('enquiry.new_form.has_diabetes_txt') }}">
                        <input type="radio" value="1" id="new_patient_problems-has_diabetes-1" name="new_patient_problems[has_diabetes]" @if((old('new_patient_problems.has_diabetes') =='1') || (!empty($new_patient_problems->has_diabetes) && $new_patient_problems->has_diabetes =='1')) checked @endif>
                        &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                        </span><span class="form-control-option">
                        <input type="radio" value="2" id="new_patient_problems-has_diabetes-2" name="new_patient_problems[has_diabetes]" @if((old('new_patient_problems.has_diabetes') =='2') || (!empty($new_patient_problems->has_diabetes) && $new_patient_problems->has_diabetes =='2')) checked @endif>
                        &nbsp;No
                </x-form.frnt_group_lyt7v1_1>

                <x-form.frnt_group_lyt7v1_1 default_class="col-lg-12" bold_label=true error="{{ $errors->first('new_patient_problems.has_ever_had_cancer') }}" label="{{ __('enquiry.new_form.has_ever_had_cancer_txt') }}">
                        <input type="radio" value="1" id="new_patient_problems-has_ever_had_cancer-1" name="new_patient_problems[has_ever_had_cancer]" @if((old('new_patient_problems.has_ever_had_cancer') =='1') || (!empty($new_patient_problems->has_ever_had_cancer) && $new_patient_problems->has_ever_had_cancer =='1')) checked @endif>
                        &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                        </span><span class="form-control-option">
                        <input type="radio" value="2" id="new_patient_problems-has_ever_had_cancer-2" name="new_patient_problems[has_ever_had_cancer]" @if((old('new_patient_problems.has_ever_had_cancer') =='2') || (!empty($new_patient_problems->has_ever_had_cancer) && $new_patient_problems->has_ever_had_cancer =='2')) checked @endif>
                        &nbsp;No
                </x-form.frnt_group_lyt7v1_1>

                <x-form.frnt_group_lyt7v1_1 default_class="col-lg-12" bold_label=true error="{{ $errors->first('new_patient_problems.has_broken_a_bone') }}" label="{{ __('enquiry.new_form.has_broken_a_bone_txt') }}">
                        <input type="radio" value="1" id="new_patient_problems-has_broken_a_bone-1" name="new_patient_problems[has_broken_a_bone]" @if((old('new_patient_problems.has_broken_a_bone') =='1') || (!empty($new_patient_problems->has_broken_a_bone) && $new_patient_problems->has_broken_a_bone =='1')) checked @endif>
                        &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                        </span><span class="form-control-option">
                        <input type="radio" value="2" id="new_patient_problems-has_broken_a_bone-2" name="new_patient_problems[has_broken_a_bone]" @if((old('new_patient_problems.has_broken_a_bone') =='2') || (!empty($new_patient_problems->has_broken_a_bone) && $new_patient_problems->has_broken_a_bone =='2')) checked @endif>
                        &nbsp;No
                </x-form.frnt_group_lyt7v1_1>

                <x-form.frnt_group_lyt7v1_1 default_class="col-lg-12" bold_label=true error="{{ $errors->first('new_patient_problems.has_metal_fixations') }}" label="{{ __('enquiry.new_form.has_metal_fixations_txt') }}">
                        <input type="radio" value="1" id="new_patient_problems-has_metal_fixations-1" name="new_patient_problems[has_metal_fixations]" @if((old('new_patient_problems.has_metal_fixations') =='1') || (!empty($new_patient_problems->has_metal_fixations) && $new_patient_problems->has_metal_fixations =='1')) checked @endif>
                        &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                        </span><span class="form-control-option">
                        <input type="radio" value="2" id="new_patient_problems-has_metal_fixations-2" name="new_patient_problems[has_metal_fixations]" @if((old('new_patient_problems.has_metal_fixations') =='2') || (!empty($new_patient_problems->has_metal_fixations) && $new_patient_problems->has_metal_fixations =='2')) checked @endif>
                        &nbsp;No
                </x-form.frnt_group_lyt7v1_1>

                <x-form.frnt_group_lyt7v1_1 default_class="col-lg-12" bold_label=true error="{{ $errors->first('new_patient_problems.do_you_smoke') }}" label="{{ __('enquiry.new_form.do_you_smoke_txt') }}">
                        <input type="radio" value="1" id="new_patient_problems-do_you_smoke-1" name="new_patient_problems[do_you_smoke]" @if((old('new_patient_problems.do_you_smoke') =='1') || (!empty($new_patient_problems->do_you_smoke) && $new_patient_problems->do_you_smoke =='1')) checked @endif>
                        &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                        </span><span class="form-control-option">
                        <input type="radio" value="2" id="new_patient_problems-do_you_smoke-2" name="new_patient_problems[do_you_smoke]" @if((old('new_patient_problems.do_you_smoke') =='2') || (!empty($new_patient_problems->do_you_smoke) && $new_patient_problems->do_you_smoke =='2')) checked @endif>
                        &nbsp;No
                </x-form.frnt_group_lyt7v1_1>
                <x-form.frnt_group_lyt7v1_1 default_class="col-lg-12" error="{{ $errors->first('new_patient_problems.smoke_much') }}" >
                    <x-form.field.text2 id="new_patient_problems-smoke_much" name="new_patient_problems[smoke_much]" placeholder="{{ __('enquiry.new_form.smoke_much_txt') }}"  value="{{ old('new_patient_problems.smoke_much') ?? $new_patient_problems->smoke_much ?? '' }}" class="form-control pq-bg-white" />
                </x-form.frnt_group_lyt7v1_1>

                <x-form.frnt_group_lyt7v1_1 default_class="col-lg-12" bold_label=true error="{{ $errors->first('new_patient_problems.has_abdominal_problems') }}" label="{{ __('enquiry.new_form.has_abdominal_problems_txt') }}">
                        <input type="radio" value="1" id="new_patient_problems-has_abdominal_problems-1" name="new_patient_problems[has_abdominal_problems]" @if((old('new_patient_problems.has_abdominal_problems') =='1') || (!empty($new_patient_problems->has_abdominal_problems) && $new_patient_problems->has_abdominal_problems =='1')) checked @endif>
                        &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                        </span><span class="form-control-option">
                        <input type="radio" value="2" id="new_patient_problems-has_abdominal_problems-2" name="new_patient_problems[has_abdominal_problems]" @if((old('new_patient_problems.has_abdominal_problems') =='2') || (!empty($new_patient_problems->has_abdominal_problems) && $new_patient_problems->has_abdominal_problems =='2')) checked @endif>
                        &nbsp;No
                </x-form.frnt_group_lyt7v1_1>

                <x-form.frnt_group_lyt7v1_1 default_class="col-lg-12" bold_label=true error="{{ $errors->first('new_patient_problems.has_previous_surgeries') }}" label="{{ __('enquiry.new_form.has_previous_surgeries_txt') }}">
                        <input type="radio" value="1" id="new_patient_problems-has_previous_surgeries-1" name="new_patient_problems[has_previous_surgeries]" @if((old('new_patient_problems.has_previous_surgeries') =='1') || (!empty($new_patient_problems->has_previous_surgeries) && $new_patient_problems->has_previous_surgeries =='1')) checked @endif>
                        &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                        </span><span class="form-control-option">
                        <input type="radio" value="2" id="new_patient_problems-has_previous_surgeries-2" name="new_patient_problems[has_previous_surgeries]" @if((old('new_patient_problems.has_previous_surgeries') =='2') || (!empty($new_patient_problems->has_previous_surgeries) && $new_patient_problems->has_previous_surgeries =='2')) checked @endif>
                        &nbsp;No
                </x-form.frnt_group_lyt7v1_1>
                <x-form.frnt_group_lyt7v1_1 default_class="col-lg-12" error="{{ $errors->first('new_patient_problems.previous_surgeries_list') }}" >
                    <x-form.field.text2 id="new_patient_problems-previous_surgeries_list" name="new_patient_problems[previous_surgeries_list]" placeholder="{{ __('enquiry.new_form.previous_surgeries_list_txt') }}"  value="{{ old('new_patient_problems.previous_surgeries_list') ?? $new_patient_problems->previous_surgeries_list ?? '' }}" class="form-control pq-bg-white" />
                </x-form.frnt_group_lyt7v1_1>




                <x-form.frnt_group_lyt7v1_1 default_class="col-lg-12" bold_label=true error="{{ $errors->first('new_patient_problems.are_you_pregnant') }}" label="{{ __('enquiry.new_form.are_you_pregnant_txt') }}">
                        <input type="radio" value="1" id="new_patient_problems-are_you_pregnant-1" name="new_patient_problems[are_you_pregnant]" @if((old('new_patient_problems.are_you_pregnant') =='1') || (!empty($new_patient_problems->are_you_pregnant) && $new_patient_problems->are_you_pregnant =='1')) checked @endif>
                        &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                        </span><span class="form-control-option">
                        <input type="radio" value="2" id="new_patient_problems-are_you_pregnant-2" name="new_patient_problems[are_you_pregnant]" @if((old('new_patient_problems.are_you_pregnant') =='2') || (!empty($new_patient_problems->are_you_pregnant) && $new_patient_problems->are_you_pregnant =='2')) checked @endif>
                        &nbsp;No
                </x-form.frnt_group_lyt7v1_1>

                <x-form.frnt_group_lyt7v1_1 default_class="col-lg-12" bold_label=true error="{{ $errors->first('new_patient_problems.has_previous_car_accident') }}" label="{{ __('enquiry.new_form.has_previous_car_accident_txt') }}">
                        <input type="radio" value="1" id="new_patient_problems-has_previous_car_accident-1" name="new_patient_problems[has_previous_car_accident]" @if((old('new_patient_problems.has_previous_car_accident') =='1') || (!empty($new_patient_problems->has_previous_car_accident) && $new_patient_problems->has_previous_car_accident =='1')) checked @endif>
                        &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                        </span><span class="form-control-option">
                        <input type="radio" value="2" id="new_patient_problems-has_previous_car_accident-2" name="new_patient_problems[has_previous_car_accident]" @if((old('new_patient_problems.has_previous_car_accident') =='2') || (!empty($new_patient_problems->has_previous_car_accident) && $new_patient_problems->has_previous_car_accident =='2')) checked @endif>
                        &nbsp;No
                </x-form.frnt_group_lyt7v1_1>
                <x-form.frnt_group_lyt7v1_1 default_class="col-lg-12" error="{{ $errors->first('new_patient_problems.previous_car_accident_date') }}" >
                    <x-form.field.text2 type="date" id="new_patient_problems-previous_car_accident_date" name="new_patient_problems[previous_car_accident_date]" placeholder="{{ __('enquiry.new_form.previous_car_accident_date_txt') }}"  value="{{ old('new_patient_problems.previous_car_accident_date') ?? $new_patient_problems->previous_car_accident_date ?? '' }}" class="form-control pq-bg-white date_empty" />
                </x-form.frnt_group_lyt7v1_1>

                

                <x-form.frnt_group_lyt7v1_1 default_class="col-lg-12" bold_label=true error="{{ $errors->first('new_patient_problems.has_any_allergies') }}" label="{{ __('enquiry.new_form.has_any_allergies_txt') }}">
                        <input type="radio" value="1" id="new_patient_problems-has_any_allergies-1" name="new_patient_problems[has_any_allergies]" @if((old('new_patient_problems.has_any_allergies') =='1') || (!empty($new_patient_problems->has_any_allergies) && $new_patient_problems->has_any_allergies =='1')) checked @endif>
                        &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                        </span><span class="form-control-option">
                        <input type="radio" value="2" id="new_patient_problems-has_any_allergies-2" name="new_patient_problems[has_any_allergies]" @if((old('new_patient_problems.has_any_allergies') =='2') || (!empty($new_patient_problems->has_any_allergies) && $new_patient_problems->has_any_allergies =='2')) checked @endif>
                        &nbsp;No
                </x-form.frnt_group_lyt7v1_1>
                <x-form.frnt_group_lyt7v1_1 default_class="col-lg-12" bold_label=true error="{{ $errors->first('new_patient_problems.has_asthma') }}" label="{{ __('enquiry.new_form.has_asthma_txt') }}">
                        <input type="radio" value="1" id="new_patient_problems-has_asthma-1" name="new_patient_problems[has_asthma]" @if((old('new_patient_problems.has_asthma') =='1') || (!empty($new_patient_problems->has_asthma) && $new_patient_problems->has_asthma =='1')) checked @endif>
                        &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                        </span><span class="form-control-option">
                        <input type="radio" value="2" id="new_patient_problems-has_asthma-2" name="new_patient_problems[has_asthma]" @if((old('new_patient_problems.has_asthma') =='2') || (!empty($new_patient_problems->has_asthma) && $new_patient_problems->has_asthma =='2')) checked @endif>
                        &nbsp;No
                </x-form.frnt_group_lyt7v1_1>
                <x-form.frnt_group_lyt7v1_1 default_class="col-lg-12" bold_label=true error="{{ $errors->first('new_patient_problems.has_other_health_problems') }}" label="{{ __('enquiry.new_form.has_other_health_problems_txt') }}">
                        <input type="radio" value="1" id="new_patient_problems-has_other_health_problems-1" name="new_patient_problems[has_other_health_problems]" @if((old('new_patient_problems.has_other_health_problems') =='1') || (!empty($new_patient_problems->has_other_health_problems) && $new_patient_problems->has_other_health_problems =='1')) checked @endif>
                        &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                        </span><span class="form-control-option">
                        <input type="radio" value="2" id="new_patient_problems-has_other_health_problems-2" name="new_patient_problems[has_other_health_problems]" @if((old('new_patient_problems.has_other_health_problems') =='2') || (!empty($new_patient_problems->has_other_health_problems) && $new_patient_problems->has_other_health_problems =='2')) checked @endif>
                        &nbsp;No
                </x-form.frnt_group_lyt7v1_1>
                <x-form.frnt_group_lyt7v1_1 default_class="col-lg-12" bold_label=true error="{{ $errors->first('new_patient_problems.has_any_other_reason') }}" label="{{ __('enquiry.new_form.has_any_other_reason_txt') }}">
                        <input type="radio" value="1" id="new_patient_problems-has_any_other_reason-1" name="new_patient_problems[has_any_other_reason]" @if((old('new_patient_problems.has_any_other_reason') =='1') || (!empty($new_patient_problems->has_any_other_reason) && $new_patient_problems->has_any_other_reason =='1')) checked @endif>
                        &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                        </span><span class="form-control-option">
                        <input type="radio" value="2" id="new_patient_problems-has_any_other_reason-2" name="new_patient_problems[has_any_other_reason]" @if((old('new_patient_problems.has_any_other_reason') =='2') || (!empty($new_patient_problems->has_any_other_reason) && $new_patient_problems->has_any_other_reason =='2')) checked @endif>
                        &nbsp;No
                </x-form.frnt_group_lyt7v1_1>

                <x-form.frnt_group_lyt7v1_1 error="{{ $errors->first('new_patient_forms.last_physiotherapy_visit') }}" label="{{ __('enquiry.new_form.last_physiotherapy_visit_txt') }}">
                    <x-form.field.text2 id="new_patient_forms-last_physiotherapy_visit" name="new_patient_forms[last_physiotherapy_visit]" placeholder="{{ __('enquiry.new_form.last_physiotherapy_visit_txt') }}"  value="{{ old('new_patient_forms.last_physiotherapy_visit') ?? $dataObj->last_physiotherapy_visit ?? '' }}" class="form-control pq-bg-white" />
                </x-form.frnt_group_lyt7v1_1>

                <x-form.frnt_group_lyt7v1_1 error="{{ $errors->first('new_patient_forms.emergency_contact_person') }}" label="{{ __('enquiry.new_form.emergency_contact_person_txt') }}">
                    <x-form.field.text2 id="new_patient_forms-emergency_contact_person" name="new_patient_forms[emergency_contact_person]" placeholder="{{ __('enquiry.new_form.emergency_contact_person_txt') }}"  value="{{ old('new_patient_forms.emergency_contact_person') ?? $dataObj->emergency_contact_person ?? '' }}" class="form-control pq-bg-white" />
                </x-form.frnt_group_lyt7v1_1>

                <x-form.frnt_group_lyt7v1_1 error="{{ $errors->first('new_patient_forms.emergency_phone') }}" label="{{ __('enquiry.new_form.emergency_phone_txt') }}">
                    <x-form.field.text2 id="new_patient_forms-emergency_phone" name="new_patient_forms[emergency_phone]" placeholder="{{ __('enquiry.new_form.emergency_phone_txt') }}"  value="{{ old('new_patient_forms.emergency_phone') ?? $dataObj->emergency_phone ?? '' }}" class="form-control pq-bg-white" />
                </x-form.frnt_group_lyt7v1_1>

                <x-form.frnt_group_lyt7v1_1 error="{{ $errors->first('new_patient_forms.client_sign') }}" label="{{ __('enquiry.new_form.client_sign_txt') }}">
                    <x-form.field.text2 id="new_patient_forms-client_sign" name="new_patient_forms[client_sign]" placeholder="{{ __('enquiry.new_form.client_sign_txt') }}"  value="{{ old('new_patient_forms.client_sign') ?? $dataObj->client_sign ?? '' }}" class="form-control pq-bg-white" />
                </x-form.frnt_group_lyt7v1_1>

            </div> -->

            {{-- BASIC INFORMATION --}}
            @include('themes.frontend.pages.partials.section.__new_patient_problems',[])

            <x-form.frnt_group_lyt7v1 default_class="col-lg-12">
                <center>
                    <div class="quote_btn pb-4 ">
                        <div class="pq-button-block">
                            <x-form.field.button3 default_class="pq-button-text me-0  " type="button" id="send_new_patient" name="send_new_patient" text="{{ __('enquiry.submit_now_txt') }}" />
                        </div>
                    </div>
                </center>
            </x-form.frnt_group_lyt7v1>
        </div>
    </form>
    <div id="msg_id"></div>

    {{-- Alert message start --}}
    @if(session()->has('alert'))
    <x-form.alert type="{{ session()->get('alert') }}" title="{{ session()->get('title') }}" message="{{ session()->get('message') }}" />
    @endif
    {{-- Alert message end --}}
    <!-- END: FORM -->

    @if ($errors->any())
    <div class="row mb-5">
        <div class="col-lg-12 alert">
            <ul>
                @foreach ($errors->all() as $error)
                <li class="alert alert-danger" role="alert" style="margin-bottom: 2px;">
                    {{ $error }}
                </li>
                @endforeach
            </ul>
        </div>
    </div>
    @endif


</div>


@push('scripts')
<script>
    // Form submit.
    $(function() {

        $.ajaxSetup({
         headers: {
            'X-CSRF-TOKEN': $('meta[name="csrf-token"]').attr('content')
         }
      });

      $.validator.setDefaults({
         ignore: []
      });

      $("#new_patient").validate({
            rules: {
                'new_patient_forms[name]': {
                    required: true
                },
                'new_patient_forms[phone]': {
                    required: true
                },
               'new_patient_forms[email]': {
                    required: true,
                    email: true
               },
            },
            messages: {
                'new_patient_forms[name]': "{{ __('web.jq_validate.enter_a_txt'). strtolower(__('enquiry.name_txt')) }}",
                'new_patient_forms[phone]': "{{ __('web.jq_validate.enter_a_txt'). strtolower(__('enquiry.new_form.phone_txt')) }}",
                'new_patient_forms[email]': {
                    required: "{{ __('web.jq_validate.enter_an_txt'). strtolower(__('enquiry.email_txt')) }}",
                },
            },
            errorPlacement: function(error, element) {
            //    console.log(element);
               if (element.attr("name") == "new_patient_forms[dob]") {
                    // error.insertAfter("#new_patient_forms-dob"); // Custom placement for preferred_date
              }else if (element.attr("name") == "application_forms[position_applied][]") {
                  error.appendTo("#position_applied_error_class");
               } else {
                  error.insertAfter(element);
               }
            }
         }),
         $("#send_new_patient").click(function(e) {
            $(".loading-wrap").show();
            var btnObj = $(this);
            e.preventDefault();
            grecaptcha.ready(function() {
               grecaptcha.execute("{{ Config('commonconstants.recaptcha.site_key') }}", {
                  action: 'new_patient_form'
               }).then(function(token) {
                  var a = $("#new_patient");
                  if (1 == a.valid()) {
                     if (token) {
                        btnObj.html("<i class=\"fa fa-refresh fa-spin text-white\"></i>&nbsp;Please wait...");
                        btnObj.attr('disabled', 'disabled');

                        $("#recaptcha_v3").val(token);
                        $("#new_patient").submit();
                     }
                  }else{
                     var firstInvalidInput = $("#new_patient :input.error:first");
                     firstInvalidInput.focus();
                    $(".loading-wrap").hide();
                  }
               });
            });
         });

      // Trigger validation when NiceSelect dropdown changes
      $('select').on('change', function() {
         $(this).valid(); // Trigger validation on the select element
         $("div.nice-select").removeClass('error'); // Adjust based on NiceSelect structure
      });

    });
</script>
@endpush