@extends('admin.layouts.app')
@section('content')
    <div class="container-xl">
        <div class="card">
            <div class="card-body p-0">
                <form method="post" action="{{ route('panel.oxygen.store') }}" class="needs-validation" novalidate=""
                    id="birth-form">
                    @csrf

                    <div class="card-header">
                        <h4>Add Oxygen</h4>
                    </div>
                    <div class="card-body">
                        <div class="row">
                            <!-- Chalani No -->
                            <div class="form-group col-md-6 col-6 mb-3">
                                <label>चलानी नं</label>
                                <input type="text" class="form-control" id="unique-input" name="chalani_no"
                                    value="{{ old('chalani_no') }}" required="" inputmode="numeric">
                                <div class="invalid-feedback">
                                    कृपया चलानी नं भर्नुहोस्
                                </div>
                            </div>

                            <!-- Subject -->
                            <div class="form-group col-md-12 col-12 mb-3">
                                <label>विषय</label>
                                <input type="text" class="form-control" name="subject" value="सिफारिस सम्बन्धमा"
                                    required="">
                                <div class="invalid-feedback">
                                    कृपया विषय भर्नुहोस्
                                </div>
                            </div>
                               <div class="form-group col-md-6 col-6 mb-3">
                                <label>अफिसकाे नाम</label>
                                <input type="text" class="form-control nepali-input" name="office_name" value="{{ old('office_name')}}"
                                    required="">
                                <div class="invalid-feedback">
                                    कृपया विषय भर्नुहोस्
                                </div>
                            </div>

                                <div class="form-group col-md-6 col-6 mb-3">
                                <label>अफिसकाे ठेगना</label>
                                <input type="text" class="form-control nepali-input" name="office_address" value="{{old('office_address')}}"
                                    required="">
                                <div class="invalid-feedback">
                                    कृपया विषय भर्नुहोस्
                                </div>
                            </div>

                            <!-- Send To Address -->
                            <div class="form-group col-md-6 col-6 mb-3">
                                <label>साविक वडा नं</label>
                                <input type="text" class="form-control nepali-input" name="previous_ward_no"
                                    value="{{ old('previous_ward_no') }}">
                                <div class="invalid-feedback">
                                    कृपया ठेगना भर्नुहोस्
                                </div>
                            </div>

                            <!-- Municipality -->
                            <div class="form-group col-md-6 col-6 mb-3">
                                <label>नगरपालिका</label>
                                <select name="municipality_id" class="form-control">
                                    <option value="">--Select--</option>
                                    @foreach ($municipalities as $municipality)
                                        <option value="{{ $municipality->id }}"
                                            {{ old('municipality_id') == $municipality->id ? 'selected' : '' }}>
                                            {{ $municipality->name }}
                                        </option>
                                    @endforeach
                                </select>
                            </div>

                            <!-- Ward No -->
                            <div class="form-group col-md-6 col-6 mb-3">
                                <label>वडा नं</label>
                                <select name="ward_id" class="form-control">
                                    <option value="">--Select--</option>
                                    @foreach ($wards as $ward)
                                        <option value="{{ $ward->id }}"
                                            {{ old('ward_id') == $ward->id ? 'selected' : '' }}>
                                            {{ $ward->name }}
                                        </option>
                                    @endforeach
                                </select>
                            </div>

                            <!-- Applicant Name -->
                            <div class="form-group col-md-6 col-6 mb-3">
                                <label>निवेदक</label>
                                <input type="text" class="form-control nepali-input" name="applicant_name"
                                    value="{{ old('applicant_name') }}" required="">
                                <div class="invalid-feedback">
                                    कृपया निवेदकको नाम भर्नुहोस्
                                </div>
                            </div>

                            <div class="form-group col-md-6 col-6 mb-3">
                                <label>लिङ्ग</label>
                                <select name="gender" class="form-control" required>
                                    <option value="">--Select--</option>
                                    <option value="Male" {{ old('gender') == 'Male' ? 'selected' : '' }}>Male</option>
                                    <option value="Female" {{ old('gender') == 'Female' ? 'selected' : '' }}>Female
                                    </option>
                                </select>
                                <div class="invalid-feedback">
                                    कृपया लिङ्ग चयन गर्नुहोस्
                                </div>
                            </div>
                            <div class="form-group col-md-6 col-6 mb-3">
                                <label>Applicant Municipality</label>
                                <input type="text" class="form-control nepali-input" name="applicant_municipality"
                                    value="{{ old('applicant_municipality') }}" required="">
                                <div class="invalid-feedback">
                                    कृपया निवेदकको नाम भर्नुहोस्
                                </div>
                            </div>
                            <div class="form-group col-md-6 col-6 mb-3">
                                <label>Applicant Ward</label>
                                <input type="text" class="form-control nepali-input" name="applicant_ward"
                                    value="{{ old('applicant_ward') }}" required="">
                                <div class="invalid-feedback">
                                    कृपया निवेदकको नाम भर्नुहोस्
                                </div>
                            </div>
                               <div class="form-group col-md-6 col-6 mb-3">
                                <label>Relation</label>
                                <input type="text" class="form-control nepali-input" name="relation"
                                    value="{{ old('relation') }}" required="">
                                <div class="invalid-feedback">
                                    कृपया निवेदकको नाम भर्नुहोस्
                                </div>
                            </div>
                               <div class="form-group col-md-6 col-6 mb-3">
                                <label>Applicant Relation</label>
                                <input type="text" class="form-control nepali-input" name="relation_name"
                                    value="{{ old('relation_name') }}" required="">
                                <div class="invalid-feedback">
                                    कृपया निवेदकको नाम भर्नुहोस्
                                </div>
                            </div>
                               <div class="form-group col-md-6 col-6 mb-3">
                                <label>Disease</label>
                                <input type="text" class="form-control nepali-input" name="disease"
                                    value="{{ old('disease') }}" required="">
                                <div class="invalid-feedback">
                                    कृपया निवेदकको नाम भर्नुहोस्
                                </div>
                            </div>

                        </div>
                    </div>
                    <div class="card-footer text-right">
                        <button type="submit" class="btn btn-primary">सुरक्षित गर्नुहोस्</button>
                        <button type="reset" class="btn btn-secondary">रद्द गर्नुहोस्</button>
                    </div>
                </form>
            </div>
        </div>
    </div>
@endsection