@extends('layouts.admin_master')

@section('content')

<main>
    <div class="container">
        <div class="row justify-content-center">
            <div class="col-lg-7">
                <div class="card shadow-lg border-0 rounded-lg mt-5">
                    <div class="card-header"><h1 class="text-center font-weight-light my-4"><b>Tambahkan Pasien</b></h1></div>
                    <div class="card-body">
                        <form method="POST" action="{{ url('/insert-customer') }}" enctype="multipart/form-data">
                        @csrf
                        
                            <div class="form-check">
                                <div class="col-md-20">
                                    <div class="form-group">
                                        <label class="small mb-1" for="inputFirstName">Tipe Pasien</label>
                                        <div class="form-check">
                                        <input class="form-check-input" type="radio" name="tipepasien" id="flexRadioDefault1">
                                        <label class="form-check-label" for="flexRadioDefault1">
                                            Pasien Baru
                                        </label>
                                        </div>
                                     <div class="form-check">

                                    <input class="form-check-input" type="radio" name="tipepasien" id="flexRadioDefault1">
                                    <label class="form-check-label" for="flexRadioDefault1">
                                        Pasien Lama
                                    </label>
                                    
                                </div>
                                
                                <div class="col-md-20">
                                    <div class="form-group">
                                        <label class="small mb-1" for="inputFirstName">Nama Pasien</label>
                                        <input class="form-control py-4" name="name" type="text" placeholder="" />
                                    </div>
                                </div>
                                <div class="col-md-20">
                                    <div class="form-group">
                                        <label class="small mb-1" for="inputFirstName">Email</label>
                                        <input class="form-control py-4" name="email" type="text" placeholder="" />
                                    </div>
                                </div>
                                <div class="col-md-20">
                                    <div class="form-group">
                                        <label class="small mb-1" for="inputLastName">No BPJS</label>
                                        <input class="form-control py-4" name="company" type="text" placeholder="" />
                                    </div>
                                </div>
                                
                                <div class="col-md-20">
                                    <div class="form-group">
                                        <label class="small mb-1" for="inputLastName">Alamat</label>
                                        <input class="form-control py-4" name="address" type="text" placeholder="" />
                                    </div>
                                </div>
                                
                                <div class="col-md-20">
                                    <div class="form-group">
                                        <label class="small mb-1" for="inputLastName">No Telepon</label>
                                        <input class="form-control py-4" name="phone" type="text" placeholder="" />
                                    </div>
                                </div>
                            </div>

                            <div class="form-group mt-4 mb-0"><button class="btn btn-primary btn-block">Submit</button></div>
                        </form>
                    </div>
                </div>
            </div>
        </div>
    </div>
</main>

@endsection