{mode === 'create' ? 'Tambah Pasien Baru' : 'Edit Data Pasien'}

{mode === 'edit' && ( No. Pasien {data.medical_record_number} )}

{/* Informasi Utama */}

Nama Lengkap * setData('name', e.target.value)} placeholder="Nama pasien" />

Jenis Kelamin * setData('gender', value)} className="flex gap-4 mt-4" >

Laki-laki

Perempuan

NIK setData('nik', e.target.value)} placeholder="16-digit NIK" maxLength={16} />

Tanggal Lahir * date && setData('birth_date', toLocalISOString(date))} initialFocus />

Tempat Lahir setData('birth_place', e.target.value)} placeholder="Kota kelahiran" />

{/* Kontak & Informasi Tambahan */}

Nomor Telepon setData('phone_number', e.target.value)} placeholder="08123456789" />

Email setData('email', e.target.value)} placeholder="joko_susanto@example.com" />

Golongan Darah

Agama

Status Pernikahan

Alamat

setData('address', e.target.value)}
                                    placeholder="Alamat lengkap"
                                />
                                <InputError message={errors.address} />
                            </div>

{/* Kontak Darurat */}
                            <div className="space-y-2">
                                <Label htmlFor="emergency_contact_name">Nama Kontak Darurat</Label>
                                <Input
                                    id="emergency_contact_name"
                                    value={data.emergency_contact_name}
                                    onChange={(e) => setData('emergency_contact_name', e.target.value)}
                                    placeholder="Nama kontak darurat"
                                />
                                <InputError message={errors.emergency_contact_name} />
                            </div>

<div className="space-y-2">
                                <Label htmlFor="emergency_contact_phone">Telepon Darurat</Label>
                                <Input
                                    id="emergency_contact_phone"
                                    value={data.emergency_contact_phone}
                                    onChange={(e) => setData('emergency_contact_phone', e.target.value)}
                                    placeholder="Nomor telepon darurat"
                                />
                                <InputError message={errors.emergency_contact_phone} />
                            </div>

<div className="space-y-2">
                                <Label htmlFor="emergency_contact_relation">Hubungan</Label>
                                <Input
                                    id="emergency_contact_relation"
                                    value={data.emergency_contact_relation}
                                    onChange={(e) => setData('emergency_contact_relation', e.target.value)}
                                    placeholder="Hubungan dengan pasien"
                                />
                                <InputError message={errors.emergency_contact_relation} />
                            </div>

{mode === 'edit' && (
                                <div className="flex items-center space-x-2">
                                    <input
                                        type="checkbox"
                                        id="is_active"
                                        checked={data.is_active}
                                        onChange={(e) => setData('is_active', e.target.checked)}
                                        className="h-4 w-4 rounded border-gray-300 text-indigo-600 focus:ring-indigo-500"
                                    />
                                    <Label htmlFor="is_active">Pasien Aktif</Label>
                                </div>
                            )}
                        </div>

<div className="flex justify-end gap-2">
                            <Button variant="outline" type="button" onClick={() => window.history.back()}>
                                Batal
                            </Button>
                            <Button type="submit" disabled={processing}>
                                {mode === 'create' ? 'Simpan' : 'Perbarui'} Pasien
                            </Button>
                        </div>
                    </form>
                </div>
            </div>
        </AppLayout>
    );
}