@extends('layouts.app')

@section('content')
    <div class="container">
        <h2 class="text-center mb-4">Registrasi Pasien Baru</h1>

            @if (session('success'))
                <div class="alert alert-success alert-dismissible fade show" role="alert">
                    <strong>Success!</strong> {{ session('success') }}
                    <button type="button" class="close" data-dismiss="alert" aria-label="Close">
                        <span aria-hidden="true">&times;</span>
                    </button>
                </div>
            @endif

            @if ($errors->any())
                <div class="alert alert-danger">
                    <ul>
                        @foreach ($errors->all() as $error)
                            <li>{{ $error }}</li>
                        @endforeach
                    </ul>
                </div>
            @endif

            <form method="POST" action="{{ route('registrasi.store') }}">
                @csrf

                <!-- Data Pasien Section -->
                <div class="card mb-4 shadow-sm">
                    <div class="card-header bg-primary text-white">
                        <h5 class="mb-0">Data Pasien</h5>
                    </div>
                    <div class="card-body">
                        <div class="row">
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label for="nik">NIK *</label>
                                    <input type="text" name="nik" class="form-control" id="nik"
                                        value="{{ old('nik') }}" required>
                                </div>
                            </div>
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label for="nama_pasien">Nama Pasien *</label>
                                    <input type="text" name="nama_pasien" class="form-control" id="nama_pasien"
                                        value="{{ old('nama_pasien') }}" required>
                                </div>
                            </div>
                        </div>

                        <div class="row">
                            <div class="col-md-4">
                                <div class="form-group">
                                    <label for="jenis_kelamin">Jenis Kelamin *</label>
                                    <select name="jenis_kelamin" id="jenis_kelamin" class="form-control" required>
                                        <option value="Laki-Laki"
                                            {{ old('jenis_kelamin') == 'Laki-Laki' ? 'selected' : '' }}>
                                            Laki-Laki</option>
                                        <option value="Perempuan"
                                            {{ old('jenis_kelamin') == 'Perempuan' ? 'selected' : '' }}>
                                            Perempuan</option>
                                    </select>
                                </div>
                            </div>
                            <div class="col-md-4">
                                <div class="form-group">
                                    <label for="tanggal_lahir">Tanggal Lahir *</label>
                                    <input type="date" name="tanggal_lahir" class="form-control" id="tanggal_lahir"
                                        value="{{ old('tanggal_lahir') }}" required>
                                </div>
                            </div>
                            <div class="col-md-4">
                                <div class="form-group">
                                    <label for="nomor_telepon">Nomor Telepon</label>
                                    <input type="text" name="nomor_telepon" class="form-control" id="nomor_telepon"
                                        value="{{ old('nomor_telepon') }}">
                                </div>
                            </div>
                        </div>
                    </div>
                </div>

                <!-- Data Registrasi Section -->
                <div class="card mb-4 shadow-sm">
                    <div class="card-header bg-primary text-white">
                        <h5 class="mb-0">Data Registrasi</h5>
                    </div>
                    <div class="card-body">
                        <div class="row">
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label for="pegawai_id">Dokter/Pegawai *</label>
                                    <select name="pegawai_id" id="pegawai_id" class="form-control" required>
                                        @foreach ($pegawai as $p)
                                            <option value="{{ $p->id }}"
                                                {{ old('pegawai_id') == $p->id ? 'selected' : '' }}>
                                                {{ $p->nama_pegawai }}
                                            </option>
                                        @endforeach
                                    </select>
                                </div>
                            </div>
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label for="ruang_pelayanan_id">Ruang Pelayanan *</label>
                                    <select name="ruang_pelayanan_id" id="ruang_pelayanan_id" class="form-control" required>
                                        @foreach ($ruang_pelayanan as $r)
                                            <option value="{{ $r->id }}"
                                                {{ old('ruang_pelayanan_id') == $r->id ? 'selected' : '' }}>
                                                {{ $r->nama_ruang_pelayanan }}
                                            </option>
                                        @endforeach
                                    </select>
                                </div>
                            </div>
                        </div>

                        <div class="row">
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label for="asuransi_id">Asuransi</label>
                                    <select name="asuransi_id" id="asuransi_id" class="form-control">
                                        @foreach ($asuransi as $a)
                                            <option value="{{ $a->id }}"
                                                {{ old('asuransi_id') == $a->id ? 'selected' : '' }}>
                                                {{ $a->nama_asuransi }}
                                            </option>
                                        @endforeach
                                    </select>
                                </div>
                            </div>
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label for="nomor_kartu_asuransi">Nomor Kartu Asuransi</label>
                                    <input type="text" name="nomor_kartu_asuransi" class="form-control"
                                        id="nomor_kartu_asuransi" value="{{ old('nomor_kartu_asuransi') }}">
                                </div>
                            </div>
                        </div>

                        <div class="row">
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label for="tanggal_registrasi">Tanggal Registrasi *</label>
                                    <input type="date" name="tanggal_registrasi" class="form-control"
                                        id="tanggal_registrasi" value="{{ old('tanggal_registrasi', date('Y-m-d')) }}"
                                        required>
                                </div>
                            </div>
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label for="keluhan">Keluhan</label>
                                    <textarea name="keluhan" id="keluhan" class="form-control">{{ old('keluhan') }}</textarea>
                                </div>
                            </div>
                        </div>
                    </div>
                </div>

                <div class="text-center">
                    <button type="submit" class="btn btn-success btn-lg">
                        <i class="fas fa-save"></i> Simpan Registrasi
                    </button>
                </div>
            </form>
    </div>
@endsection