{{ Form::label('patient_id', __('messages.patient_admission.patient') . ':', ['class' => 'form-label']) }} {{ Form::select('patient_id', $data['patients'], null, ['class' => 'form-select select2Selector', 'id' => 'admissionPatientId', 'placeholder' => __('messages.document.select_patient'), 'data-control' => 'select2', 'required', isset($patientAdmission->patient_admission_id) ? 'disabled' : '']) }} @if (isset($patientAdmission->patient_admission_id)) {{ Form::hidden('patient_id', $patientAdmission->patient_admission_id) }} @endif

{{ Form::label('doctor_id', __('messages.patient_admission.doctor') . ':', ['class' => 'form-label']) }} {{ Form::select('doctor_id', $data['doctors'], null, ['class' => 'form-select select2Selector', 'id' => 'admissionDoctorId', 'placeholder' => __('messages.web_home.select_doctor'), 'data-control' => 'select2', 'required']) }}

{{ Form::label('admission_date', __('messages.patient_admission.admission_date') . ':', ['class' => 'form-label']) }} {{ Form::text('admission_date', null, ['class' => (getLoggedInUser()->thememode ? 'bg-light form-control' : 'bg-white form-control'),'id' => 'admissionDate','required','autocomplete' => 'off','placeholder'=>__('messages.patient_admission.admission_date')]) }}

{{ Form::label('package_id', __('messages.patient_admission.package') . ':', ['class' => 'form-label']) }} {{ Form::select('package_id', $data['packages'], null, ['class' => 'form-select select2Selector', 'id' => 'admissionPackageId', 'placeholder' => __('messages.common.choose') . ' ' . __('messages.package.package'), 'data-control' => 'select2']) }}

{{ Form::label('insurance_id', __('messages.patient_admission.insurance') . ':', ['class' => 'form-label']) }} {{ Form::select('insurance_id', $data['insurances'], null, ['class' => 'form-select select2Selector', 'id' => 'admissionInsuranceId', 'placeholder' => __('messages.common.choose') . ' ' . __('messages.patient_admission.insurance'), 'data-control' => 'select2']) }}

{{ Form::label('bed_id', __('messages.patient_admission.bed') . ':', ['class' => 'form-label']) }} {{ Form::select('bed_id', $data['beds'], null, ['class' => 'form-select select2Selector', 'id' => 'admissionBedId', 'placeholder' => __('messages.common.choose') . ' ' . __('messages.bed_assign.bed'), 'data-control' => 'select2']) }}

{{ Form::label('policy_no', __('messages.patient_admission.policy_no').':', ['class' => 'form-label']) }} {{ Form::text('policy_no', null, ['class' => 'form-control','placeholder'=>__('messages.patient_admission.policy_no')]) }}

{{ Form::label('agent_name', __('messages.patient_admission.agent_name').':', ['class' => 'form-label']) }} {{ Form::text('agent_name', null, ['class' => 'form-control','placeholder'=>__('messages.patient_admission.agent_name')]) }}

{{ Form::label('guardian_name', __('messages.patient_admission.guardian_name').':', ['class' => 'form-label']) }} {{ Form::text('guardian_name', null, ['class' => 'form-control','placeholder'=>__('messages.patient_admission.guardian_name')]) }}

{{ Form::label('guardian_relation', __('messages.patient_admission.guardian_relation').':', ['class' => 'form-label']) }} {{ Form::text('guardian_relation', null, ['class' => 'form-control','placeholder'=>__('messages.patient_admission.guardian_relation')]) }}

{{ Form::label('guardian_contact', __('messages.patient_admission.guardian_contact') . ':', ['class' => 'form-label']) }}
{{ Form::text('guardian_contact', $patientAdmission->guardian_contact ?? getCountryCode(), ['class' => 'form-control phoneNumber', 'id' => 'admissionPhoneNumber', 'onkeyup' => 'if (/\D/g.test(this.value)) this.value = this.value.replace(/\D/g,"")']) }} {{ Form::hidden('prefix_code', null, ['class' => 'prefix_code']) }} {{ Form::hidden('country_iso', null, ['class' => 'country_iso']) }} ✓   {{ __('messages.valid') }}

{{ Form::label('guardian_address', __('messages.patient_admission.guardian_address').':', ['class' => 'form-label']) }} {{ Form::text('guardian_address', null, ['class' => 'form-control','placeholder'=>__('messages.patient_admission.guardian_address')]) }}