{% extends "base.html" %}
{% load static %}

{% block title %}Patient Registration - {{ block.super }}{% endblock %}

{% block content %}
<div class="container-fluid">
    <div class="row">
        <div class="col-12">
            <div class="card">
                <div class="card-header">
                    <h4 class="card-title mb-0">
                        <i class="fas fa-user-plus me-2"></i>Patient Registration
                    </h4>
                </div>
                
                <div class="card-body">
                    <form id="patient-registration-form" method="post">
                        {% csrf_token %}
                        
                        <!-- Personal Information -->
                        <div class="row mb-4">
                            <div class="col-12">
                                <h5 class="border-bottom pb-2">Personal Information</h5>
                            </div>
                            <div class="col-md-4">
                                <div class="mb-3">
                                    <label for="first_name" class="form-label">First Name *</label>
                                    <input type="text" class="form-control" id="first_name" name="first_name" required>
                                </div>
                            </div>
                            <div class="col-md-4">
                                <div class="mb-3">
                                    <label for="last_name" class="form-label">Last Name *</label>
                                    <input type="text" class="form-control" id="last_name" name="last_name" required>
                                </div>
                            </div>
                            <div class="col-md-4">
                                <div class="mb-3">
                                    <label for="middle_name" class="form-label">Middle Name</label>
                                    <input type="text" class="form-control" id="middle_name" name="middle_name">
                                </div>
                            </div>
                            <div class="col-md-4">
                                <div class="mb-3">
                                    <label for="date_of_birth" class="form-label">Date of Birth *</label>
                                    <input type="date" class="form-control" id="date_of_birth" name="date_of_birth" required>
                                </div>
                            </div>
                            <div class="col-md-4">
                                <div class="mb-3">
                                    <label for="gender" class="form-label">Gender *</label>
                                    <select class="form-select" id="gender" name="gender" required>
                                        <option value="">Select gender...</option>
                                        <option value="MALE">Male</option>
                                        <option value="FEMALE">Female</option>
                                        <option value="OTHER">Other</option>
                                        <option value="UNKNOWN">Prefer not to say</option>
                                    </select>
                                </div>
                            </div>
                            <div class="col-md-4">
                                <div class="mb-3">
                                    <label for="ssn" class="form-label">SSN</label>
                                    <input type="text" class="form-control" id="ssn" name="ssn" placeholder="XXX-XX-XXXX">
                                </div>
                            </div>
                        </div>

                        <!-- Contact Information -->
                        <div class="row mb-4">
                            <div class="col-12">
                                <h5 class="border-bottom pb-2">Contact Information</h5>
                            </div>
                            <div class="col-md-6">
                                <div class="mb-3">
                                    <label for="phone_number" class="form-label">Phone Number</label>
                                    <input type="tel" class="form-control" id="phone_number" name="phone_number">
                                </div>
                            </div>
                            <div class="col-md-6">
                                <div class="mb-3">
                                    <label for="email" class="form-label">Email Address</label>
                                    <input type="email" class="form-control" id="email" name="email">
                                </div>
                            </div>
                            <div class="col-12">
                                <div class="mb-3">
                                    <label for="address" class="form-label">Address</label>
                                    <textarea class="form-control" id="address" name="address" rows="2"></textarea>
                                </div>
                            </div>
                        </div>

                        <!-- Emergency Contact -->
                        <div class="row mb-4">
                            <div class="col-12">
                                <h5 class="border-bottom pb-2">Emergency Contact</h5>
                            </div>
                            <div class="col-md-4">
                                <div class="mb-3">
                                    <label for="emergency_name" class="form-label">Full Name *</label>
                                    <input type="text" class="form-control" id="emergency_name" name="emergency_name" required>
                                </div>
                            </div>
                            <div class="col-md-4">
                                <div class="mb-3">
                                    <label for="emergency_relationship" class="form-label">Relationship *</label>
                                    <select class="form-select" id="emergency_relationship" name="emergency_relationship" required>
                                        <option value="">Select relationship...</option>
                                        <option value="SPOUSE">Spouse</option>
                                        <option value="PARENT">Parent</option>
                                        <option value="CHILD">Child</option>
                                        <option value="SIBLING">Sibling</option>
                                        <option value="FRIEND">Friend</option>
                                        <option value="OTHER">Other</option>
                                    </select>
                                </div>
                            </div>
                            <div class="col-md-4">
                                <div class="mb-3">
                                    <label for="emergency_phone" class="form-label">Phone Number *</label>
                                    <input type="tel" class="form-control" id="emergency_phone" name="emergency_phone" required>
                                </div>
                            </div>
                        </div>

                        <!-- Insurance Information -->
                        <div class="row mb-4">
                            <div class="col-12">
                                <h5 class="border-bottom pb-2">Insurance Information</h5>
                            </div>
                            <div class="col-md-6">
                                <div class="mb-3">
                                    <label for="insurance_provider" class="form-label">Insurance Provider</label>
                                    <input type="text" class="form-control" id="insurance_provider" name="insurance_provider">
                                </div>
                            </div>
                            <div class="col-md-6">
                                <div class="mb-3">
                                    <label for="insurance_policy_number" class="form-label">Policy Number</label>
                                    <input type="text" class="form-control" id="insurance_policy_number" name="insurance_policy_number">
                                </div>
                            </div>
                        </div>

                        <!-- Consent Forms -->
                        {% if consent_templates %}
                        <div class="row mb-4">
                            <div class="col-12">
                                <h5 class="border-bottom pb-2">Consent Forms</h5>
                                {% for template in consent_templates %}
                                <div class="form-check mb-2">
                                    <input class="form-check-input" type="checkbox" 
                                           id="consent_{{ template.id }}" 
                                           name="consent_templates" 
                                           value="{{ template.id }}"
                                           {% if template.is_required %}required{% endif %}>
                                    <label class="form-check-label" for="consent_{{ template.id }}">
                                        {{ template.name }}
                                        {% if template.is_required %}<span class="text-danger">*</span>{% endif %}
                                    </label>
                                    {% if template.description %}
                                    <div class="form-text">{{ template.description }}</div>
                                    {% endif %}
                                </div>
                                {% endfor %}
                            </div>
                        </div>
                        {% endif %}

                        <!-- Submit Buttons -->
                        <div class="row">
                            <div class="col-12">
                                <div class="d-flex justify-content-end gap-2">
                                    <button type="button" class="btn btn-secondary">Cancel</button>
                                    <button type="submit" class="btn btn-primary">
                                        <i class="fas fa-save me-1"></i>Register Patient
                                    </button>
                                </div>
                            </div>
                        </div>
                    </form>
                </div>
            </div>
        </div>
    </div>
</div>
{% endblock %}

{% block js %}
<script>
document.addEventListener('DOMContentLoaded', function() {
    // Form validation and submission
    document.getElementById('patient-registration-form').addEventListener('submit', function(e) {
        e.preventDefault();
        
        // Basic validation
        const requiredFields = this.querySelectorAll('[required]');
        let isValid = true;
        
        requiredFields.forEach(field => {
            if (!field.value.trim()) {
                field.classList.add('is-invalid');
                isValid = false;
            } else {
                field.classList.remove('is-invalid');
            }
        });
        
        if (isValid) {
            // Submit form
            this.submit();
        }
    });
    
    // SSN formatting
    document.getElementById('ssn').addEventListener('input', function(e) {
        let value = e.target.value.replace(/\D/g, '');
        if (value.length >= 6) {
            value = value.substring(0,3) + '-' + value.substring(3,5) + '-' + value.substring(5,9);
        } else if (value.length >= 4) {
            value = value.substring(0,3) + '-' + value.substring(3);
        }
        e.target.value = value;
    });
});
</script>
{% endblock %}