<?php $page = 'pharmacy-register-step3'; ?>
@extends('layout.mainlayout')
@section('content')
    <!-- Page Content -->
    <div class="content login-page pt-0">
        <div class="container-fluid">
            
            <!-- Register Content -->
            <div class="account-content">
                <div class="d-flex align-items-center justify-content-center">
                    <div class="login-right">
                        <div class="inner-right-login">
                            <div class="login-header">
                                <div class="logo-icon">
                                    <img src="{{ URL::asset('assets/img/logo.png')}}" alt="kafu-logo">
                                </div>
                                <div class="step-list">
                                    <ul>
                                        <li><a href="javascript:;" class="active-done">1</a></li>
                                        <li><a href="javascript:;" class="active-done">2</a></li>
                                        <li><a href="javascript:;" class="active">3</a></li>
                                    </ul>
                                </div>
                                <form id="personal_details" enctype="multipart/form-data">  
                                    <div class="pregnant-col pt-4">
                                        <div>
                                            <div class="remember-me-col d-flex justify-content-between">
                                                <span class="mt-1">Are you Registered</span>
                                                <label class="custom_check">
                                                    <input type="checkbox" class="" id="is_registered" name="pregnant" value="1">
                                                    <span class="checkmark"></span>
                                                </label>
                                            </div>
                                        </div>
                                    </div>
                                    <div class="step-process-col mt-4">
                                        <div class="mb-3" id="preg_div" style="display: none;">
                                            <label class="mb-2">How Many Years you have been Registered?</label>
                                            <select class="form-select form-control select" id="preg_term" name="preg_term" tabindex="-1" aria-hidden="true">
                                                <option value="">Select year</option>
                                                <option value="1">1</option>
                                                <option value="2">2</option>
                                                <option value="3">3</option>
                                                <option value="4">4</option>
                                                <option value="5">5</option>
                                                <option value="6">6</option>
                                                <option value="7">7</option>
                                                <option value="8">8</option>
                                                <option value="9">9</option>
                                                <option value="10">10</option>
                                            </select>
                                        </div>
                                         <div class="mb-3">
                                            <label class="mb-2">Address line 1</label>
                                            <input type="text" placeholder="Address line 1" class="form-control" id="address1" value="" name="address1">
                                        </div>
                                        <div class="mb-3">
                                            <label class="mb-2">Address line 2</label>
                                            <input type="text" placeholder="Address line 2" class="form-control" id="address2" value="" name="address2">
                                        </div>
                                        <div class="mb-3">
                                            <label class="mb-2">Postal/Zip code</label>
                                            <input type="text" placeholder="Postal/Zip code" class="form-control" id="postal" value="" name="postal">
                                        </div>
                                        <div class="mb-3">
                                            <label class="mb-2">Certification and Employer</label>
                                            <div class="row justify-content-center">
                                                 <div class="profile-pic-upload d-flex flex-wrap  justify-content-center">
                                                    <div class="cam-col">
                                                        <img src="{{ URL::asset('assets/img/icons/camera.svg')}}" alt="camera-image">
                                                    </div>
                                                    <span class="text-center">Upload Rigth To sell Certigifcate</span>
                                                    <input type="file" id="right_to_sell" name="right_to_sell">
                                                </div>
                                                  <div class="profile-pic-upload d-flex flex-wrap  justify-content-center">
                                                    <div class="cam-col">
                                                        <img src="{{ URL::asset('assets/img/icons/camera.svg')}}" alt="camera-image">
                                                    </div>
                                                    <span class="text-center">Upload Photo ID</span>
                                                    <input type="file" id="photo_id" name="photo_id">
                                                </div>
                                                  <div class="profile-pic-upload d-flex flex-wrap  justify-content-center">
                                                    <div class="cam-col">
                                                        <img src="{{ URL::asset('assets/img/icons/camera.svg')}}" alt="camera-image">
                                                    </div>
                                                    <span class="text-center">Upload Clinical employment</span>
                                                    <input type="file" id="c_employment" name="c_employment">
                                                </div>
                                            </div>
                                        </div>
                                        <div class="checklist-col pregnant-col">
                                            <div class="remember-me-col d-flex justify-content-between">
                                                <span class="mt-1">Do you Deliver?</span>
                                                <label class="custom_check mb-3">
                                                    <input type="checkbox" class="" name="deliver" id="deliver" value="1">
                                                    <span class="checkmark"></span>
                                                </label>
                                            </div>
                                            <div class="remember-me-col d-flex justify-content-between">
                                                <span class="mt-1">Do you Offer appoinment?</span>
                                                <label class="custom_check mb-3">
                                                    <input type="checkbox" class="" name="appoinment" id="appoinment" value="1">
                                                    <span class="checkmark"></span>
                                                </label>
                                            </div>
                                            <div class="remember-me-col d-flex justify-content-between">
                                                <span class="mt-1">Do you honour free prescription?</span>
                                                <label class="custom_check mb-3">
                                                    <input type="checkbox" class="" name="prescription" id="prescription" value="1">
                                                    <span class="checkmark"></span>
                                                </label>
                                            </div>
                                        </div>
                                    </div>
                                    <div class="mt-5">
                                        <a href="{{url('pharmacy-index')}}" class="btn btn-primary w-100 btn-lg login-btn step2_submit" id="step2_button" >Continue </a>
                                    </div>
                                </form>
                            </div>
                        </div>
                        <div class="login-bottom-copyright">
                            <span>© <script>document.write(new Date().getFullYear())</script> Doccure. All rights reserved.</span>
                        </div>
                    </div>
                </div>
            </div>
            <!-- /Register Content -->

        </div>

    </div>
    <!-- /Page Content -->
@endsection
