@extends('themes.frontend.layouts.app')
@section('flatpickr') @stop
@section('validate') @stop

@if (isset($dataArr['meta_title']))
@section('page-title'){{ $dataArr['meta_title'] }}@stop
@else
@section('page-title'){{ $dataArr['title'] }}@stop
@endif
@if (isset($dataArr['meta_key']))
@section('meta-keywords'){{ $dataArr['meta_key'] }}@stop
@endif
@if (isset($dataArr['meta_descp']))
@section('meta-description'){{ $dataArr['meta_descp'] }}@stop
@endif
@if (isset($dataArr['image_path']))
@section('meta-image'){{ $dataArr['image_path'] }}@stop
@endif
@if ($dataArr['full_url'])
@section('cur-url'){{ $dataArr['full_url'] }}@stop
@endif

@push('styles')
@if(isset($dataArr['custom_fields']['textarea_4']) && $dataArr['custom_fields']['textarea_4'] && $dataArr['custom_fields']['textarea_4']['value'])
<!--====== START: CUSTOM PAGE CSS from backed the Page ======-->
<style scoped>
		{!! $dataArr['custom_fields']['textarea_4']['value'] !!}
</style>
<!--====== END: CUSTOM PAGE CSS from backed the Page ======-->
@endif
@endpush

@section('content')
<!--====== BANNER PART START ======-->
@include('themes.frontend.includes.breadcrumb',['titleClass'=>'text-white'])
<!--====== BANNER PART ENDS ======-->

<!--==================================================-->
<!-----Start contact Section Style Seven ----->
<!--===================================================-->
@if (isset($dataArr['custom_fields']['editor_1']))
    {!!  app(App\Services\ShortcodeProcessor::class)->process($dataArr['custom_fields']['editor_1']['value']) !!}
@endif

<style>
  a.pq-button-text {
    padding: 12px 30px;
    font-size: 14px;
    font-weight: 600;
    background: var(--primary-color);
    font-family: var(--title-fonts);
    text-transform: uppercase;
    letter-spacing: 0.04em;
    color: var(--white-color);
    display: inline-block;
    border: none;
    width: auto;
    height: auto;
    line-height: 2;
    transition: all 0.5s ease-in-out;
    -moz-transition: all 0.5s ease-in-out;
    -ms-transition: all 0.5s ease-in-out;
    -o-transition: all 0.5s ease-in-out;
    -webkit-transition: all 0.5s ease-in-out;
  }
  a.pq-button-text:hover {
    background: var(--dark-color);
  }
</style>

<section class="appoinment-form  appointment-page pt-pb-130 ">
    <div class="container">
      	<div class="row">
        	<div class="col-xl-12">
				<div class="appoinment-box">
					<center>
						<h1>ALLISTON PHYSIOTHERAPY &amp; SPORTS REHABILITATION</h1>
						<h4>Respectful Conduct Policy</h4>
					</center>
					@if(session('success'))
						<div class="alert alert-success">{{ session('success') }}</div>
					@endif
					<div class="row">
						<form action="{{ url('respectful-conduct-policy-process') }}" name="new_patient" id="new_patient" method="post" novalidate="novalidate">
							@csrf
							<div class="pq-appointment">
								<div class="row">
									<div class="col-lg-12">
										<h6 class="text-white">PART A - Pertaining to Extended Health Care Centre</h6>
										<p>At Alliston Physiotherapy and Sports Rehabilitation, we are committed to providing a safe, respectful, and supportive environment for both our clients and staff.<br><strong>Abusive language, aggressive behavior, or any form of misconduct toward our staff will not be tolerated.</strong><br>We appreciate your cooperation in maintaining a positive and professional atmosphere for everyone.<br>— Management Of Alliston Physiotherapy and Sports Rehabilitation</p>
									</div>
									<div class="col-lg-6  ">
										Patient Signature 
										<span class="required text-danger">*</span>		
										<input class="form-control pq-bg-white paitent-name-field" id="" name="patient_signature" required="required" type="text"   placeholder=""   autocomplete="off" value="{{ old('patient_signature') }}">
										@error('patient_signature') <span class="text-danger">{{ $message }}</span> @enderror
									</div> 
									<div class="col-lg-6  ">
										Date 
										<span class="required text-danger">*</span>		
										<input class="form-control pq-bg-white paitent-dob-field date_empty" id="" name="date" required="required" type="date"   placeholder=""   autocomplete="off" value="{{ old('date') }}">
										@error('date') <span class="text-danger">{{ $message }}</span> @enderror
									</div>
									<div class="col-lg-12">
										<h6 class="text-white">OFFICE USE ONLY- INSURANCE INFORMATION</h6>
									</div>
									<div class="col-lg-6  ">
										Insurance Name
										<span class="required text-danger">*</span>		
										<input class="form-control pq-bg-white paitent-name-field" id="" name="insurance_name" required="required" type="text"   placeholder=""   autocomplete="off" value="{{ old('insurance_name') }}">
										@error('insurance_name') <span class="text-danger">{{ $message }}</span> @enderror
									</div> 
									<div class="col-lg-6  ">
										Member Name
										<span class="required text-danger">*</span>		
										<input class="form-control pq-bg-white paitent-name-field" id="" name="member_name" required="required" type="text"   placeholder=""   autocomplete="off" value="{{ old('member_name') }}">
										@error('member_name') <span class="text-danger">{{ $message }}</span> @enderror
									</div> 
									<div class="col-lg-6  ">
										Policy Number 
										<span class="required text-danger">*</span>		
										<input class="form-control pq-bg-white paitent-name-field" id="" name="policy_number" required="required" type="text"   placeholder=""   autocomplete="off" value="{{ old('policy_number') }}">
										@error('policy_number') <span class="text-danger">{{ $message }}</span> @enderror
									</div>
									<div class="col-lg-6  ">
										ID Number 
										<span class="required text-danger">*</span>		
										<input class="form-control pq-bg-white paitent-name-field" id="" name="id_number" required="required" type="text"   placeholder=""   autocomplete="off" value="{{ old('id_number') }}">
										@error('id_number') <span class="text-danger">{{ $message }}</span> @enderror
									</div>
									<div class="col-lg-6  ">
										Total Max for Physio
										<span class="required text-danger">*</span>		
										<input class="form-control pq-bg-white paitent-name-field" id="" name="total_max_for_physio" required="required" type="text"   placeholder="$"   autocomplete="off" value="{{ old('total_max_for_physio') }}">
										@error('total_max_for_physio') <span class="text-danger">{{ $message }}</span> @enderror
									</div> 
									<div class="col-lg-6  ">
										Percentage
										<span class="required text-danger">*</span>		
										<input class="form-control pq-bg-white paitent-name-field" id="" name="physio_percentage" required="required" type="text"   placeholder=""   autocomplete="off" value="{{ old('physio_percentage') }}">
										@error('physio_percentage') <span class="text-danger">{{ $message }}</span> @enderror
									</div> 
									<div class="col-lg-6  ">
										Total for Massage
										<span class="required text-danger">*</span>		
										<input class="form-control pq-bg-white paitent-name-field" id="" name="total_for_massage" required="required" type="text"   placeholder="$"   autocomplete="off" value="{{ old('total_for_massage') }}">
										@error('total_for_massage') <span class="text-danger">{{ $message }}</span> @enderror
									</div> 
									<div class="col-lg-6  ">
										Percentage
										<span class="required text-danger">*</span>		
										<input class="form-control pq-bg-white paitent-name-field" id="" name="massage_percentage" required="required" type="text"   placeholder=""   autocomplete="off" value="{{ old('massage_percentage') }}">
										@error('massage_percentage') <span class="text-danger">{{ $message }}</span> @enderror
									</div> 
									<div class="col-lg-6  ">
										Total Max for Braces
										<span class="required text-danger">*</span>		
										<input class="form-control pq-bg-white paitent-name-field" id="" name="total_max_for_braces" required="required" type="text"   placeholder="$"   autocomplete="off" value="{{ old('total_max_for_braces') }}">
										@error('total_max_for_braces') <span class="text-danger">{{ $message }}</span> @enderror
									</div> 
									<div class="col-lg-6  ">
										Percentage
										<span class="required text-danger">*</span>		
										<input class="form-control pq-bg-white paitent-name-field" id="" name="braces_percentage" required="required" type="text"   placeholder=""   autocomplete="off" value="{{ old('braces_percentage') }}">
										@error('braces_percentage') <span class="text-danger">{{ $message }}</span> @enderror
									</div> 
									<div class="col-lg-12 ">
										Policy year/Calendar year
										<span class="required text-danger">*</span>		
										<input class="form-control pq-bg-white paitent-name-field" id="" name="policy_year" required="required" type="text"   placeholder=""   autocomplete="off" value="{{ old('policy_year') }}">
										@error('policy_year') <span class="text-danger">{{ $message }}</span> @enderror
									</div> 
									<div class="col-lg-6  ">
										Update On
										<span class="required text-danger">*</span>		
										<input class="form-control pq-bg-white paitent-dob-field date_empty" id="" name="update_on" required="required" type="date"   placeholder=""   autocomplete="off" value="{{ old('update_on') }}">
										@error('update_on') <span class="text-danger">{{ $message }}</span> @enderror
									</div> 
									<div class="col-lg-6  ">
										By
										<span class="required text-danger">*</span>		
										<input class="form-control pq-bg-white paitent-name-field" id="" name="update_by" required="required" type="text"   placeholder=""   autocomplete="off" value="{{ old('update_by') }}">
										@error('update_by') <span class="text-danger">{{ $message }}</span> @enderror
									</div>
								</div>
                				<div class="row">
									<div class="col-lg-4">
                    					<div class="quote_btn pb-4" style="text-align: left;">
											<div class="pq-button-block">
												<a class="pq-button-text me-0" href="informed-consent-physiotherapy-treatment"><i class="fas fa-angle-double-left"></i> Back</a>
											</div>
										</div>
                  					</div>
									<div class="col-lg-4">&nbsp;</div>
									<div class="col-lg-4">
										<div class="quote_btn pb-4" style="text-align: right;">
											<div class="pq-button-block">
												<button type="submit" class="pq-button-text me-0" id="send_new_patient" name="send_new_patient">Next <i class="fas fa-angle-double-right"></i></button>
											</div>
										</div>
									</div>
								</div>
							</div>
						</form>
						<!-- END: FORM -->
					</div>
				</div>
			</div>
		</div>
	</div>
</section>
@stop