@if (!$referral_direct->id)
{!! Form::select('division_id')->required()->options(Company::divisions(), user('admin.web')->division_id)->value($referral_direct->division_id)->label(trans('referral_clinic::referral_patient.label.division_id'))->placeholder(trans('referral_clinic::referral_patient.placeholder.division_id'))->addGroupClass('form-group-sm') !!}
@else
{!! Form::select('division_id')->required()->options(Company::divisions(), $referral->division_id)->value($referral_direct->division_id)->label(trans('referral_clinic::referral_patient.label.division_id'))->placeholder(trans('referral_clinic::referral_patient.placeholder.division_id'))->addGroupClass('form-group-sm') !!}
@endif
{!! Form::text('created_date')
->label('Created Date & Time')
->value(isset($referral_direct) && $referral_direct->created_at ? format_date_time($referral_direct->created_at) : '')
->readonly()
->addGroupClass('form-group-sm') !!}
{!! Form::text('created_by')
->label('Created By')
->value($referral_direct->user_id ? $referral_direct->user->name : user('admin.web')->name)
->readonly()
->addGroupClass('form-group-sm') !!}
{!! Form::text('referring_hospital')->label(trans('referral_clinic::referral_direct.label.referring_hospital'))->placeholder(trans('referral_clinic::referral_direct.placeholder.referring_hospital'))->addGroupClass('form-group-sm') !!}
{!! Form::text('referring_doctor')->label(trans('referral_clinic::referral_direct.label.referring_doctor'))->placeholder(trans('referral_clinic::referral_direct.placeholder.referring_doctor'))->addGroupClass('form-group-sm') !!}
{!! Form::tel('referring_number')->label(trans('referral_clinic::referral_direct.label.referring_number'))->placeholder(trans('referral_clinic::referral_direct.placeholder.referring_number'))->addGroupClass('form-group-sm') !!}
{!! Form::email('referring_email')->label(trans('referral_clinic::referral_direct.label.referring_email'))->placeholder(trans('referral_clinic::referral_direct.placeholder.referring_email'))->addGroupClass('form-group-sm') !!}
{!! Form::text('referring_department')->label(trans('referral_clinic::referral_direct.label.referring_department'))->placeholder(trans('referral_clinic::referral_direct.placeholder.referring_department'))->addGroupClass('form-group-sm') !!}
{!! Form::textarea('referring_hospital_address')->label(trans('referral_clinic::referral_direct.label.referring_hospital_address'))->placeholder(trans('referral_clinic::referral_direct.placeholder.referring_hospital_address'))->addGroupClass('form-group-sm') !!}
{!! Form::text('patient_name')->required()->label(trans('referral_clinic::referral_direct.label.patient_name'))->placeholder(trans('referral_clinic::referral_direct.placeholder.patient_name'))->addGroupClass('form-group-sm') !!}
{!! Form::number('patient_age')->required()->min(0)->max(120)->label(trans('referral_clinic::referral_direct.label.patient_age'))->placeholder(trans('referral_clinic::referral_direct.placeholder.patient_age'))->addGroupClass('form-group-sm') !!}
{!! Form::select('patient_gender')->required()->options(trans('referral_clinic::referral_direct.options.patient_gender'))->label(trans('referral_clinic::referral_direct.label.patient_gender'))->placeholder(trans('referral_clinic::referral_direct.placeholder.patient_gender'))->addGroupClass('form-group-sm') !!}
{!! Form::tel('patient_number')->required()->label(trans('referral_clinic::referral_direct.label.patient_number'))->placeholder(trans('referral_clinic::referral_direct.placeholder.patient_number'))->addGroupClass('form-group-sm') !!}
{!! Form::text('patient_condition')->required()->label(trans('referral_clinic::referral_direct.label.patient_condition'))->placeholder(trans('referral_clinic::referral_direct.placeholder.patient_condition'))->addGroupClass('form-group-sm') !!}
{!! Form::select('patient_urgency_level')->required()->options(trans('referral_clinic::referral_direct.options.patient_urgency_level'))->label(trans('referral_clinic::referral_direct.label.patient_urgency_level'))->placeholder(trans('referral_clinic::referral_direct.placeholder.patient_urgency_level'))->addGroupClass('form-group-sm') !!}
{!! Form::select('requested_treatment')->options(trans('referral_clinic::referral_direct.options.requested_treatment'))->required()->label(trans('referral_clinic::referral_direct.label.requested_treatment'))->placeholder(trans('referral_clinic::referral_direct.placeholder.requested_treatment'))->addGroupClass('form-group-sm') !!}
{!! Form::select('doctor_department_id')->required()->options(ReferralClinic::doctor_departments())->label(trans('referral_clinic::referral_direct.label.doctor_department_id'))->placeholder(trans('referral_clinic::referral_direct.placeholder.doctor_department_id'))->addGroupClass('form-group-sm') !!}
{!! Form::text('expected_date_of_arrival') ->value($referral_direct->expected_date_of_arrival ? format_date($referral_direct->expected_date_of_arrival) : '')->addClass('datepick')->id('expected_date_of_arrival')->label('Expected Date of Arrival')->placeholder(trans('referral_clinic::referral_direct.placeholder.expected_date_of_arrival'))->addGroupClass('form-group-sm')->required()->disabled(isset($referral_direct) && $referral_direct->id) !!}
{!! Form::text('expected_time_of_arrival')->addClass('pickatime')->label('Expected Time of Arrival')->placeholder(trans('referral_clinic::referral_direct.placeholder.expected_time_of_arrival'))->addGroupClass('form-group-sm')->required()->disabled(isset($referral_direct) && $referral_direct->id) !!}
{!! Form::select('transport_mode')->options(trans('referral_clinic::referral_direct.options.transport_mode'))->label(trans('referral_clinic::referral_direct.label.transport_mode'))->placeholder(trans('referral_clinic::referral_direct.placeholder.transport_mode'))->addGroupClass('form-group-sm') !!}
@if(!$referral_direct->id)
{!! Form::select('status')->options(['Pending' => 'Pending'])->disabled()->value('Pending')->label(trans('referral_clinic::referral_direct.label.status'))->placeholder(trans('referral_clinic::referral_direct.placeholder.status'))->addGroupClass('form-group-sm') !!}
{!! Form::hidden('status', 'Pending') !!}
@else
{!! Form::select('status')->required()->options(trans('referral_clinic::referral_direct.options.status'))->label(trans('referral_clinic::referral_direct.label.status'))->placeholder(trans('referral_clinic::referral_direct.placeholder.status'))->addGroupClass('form-group-sm') !!}
{!! Form::text('elapsed time_')
->label('Elapsed Time')
->value($referral_direct->elapsed_time ? secondsToDayHourMinutes($referral_direct->elapsed_time) : '')
->readonly()
->addGroupClass('form-group-sm') !!}
{!! Form::text('date_of_arrival')->addClass('datepick')->id('date_of_arrival')->label('Date of Arrival')->placeholder(trans('referral_clinic::referral_direct.placeholder.date_of_arrival'))->addGroupClass('form-group-sm') !!}
{!! Form::text('time_of_arrival')->addClass('pickatime')->label('Time of Arrival')->placeholder(trans('referral_clinic::referral_direct.placeholder.time_of_arrival'))->addGroupClass('form-group-sm') !!}
@endif
{!! Form::textarea('remarks')->label(trans('referral_clinic::referral_direct.label.remarks'))->placeholder(trans('referral_clinic::referral_direct.placeholder.remarks'))->addGroupClass('form-group-sm') !!}