<div class="wrapper wrapper-content">

    {$action = 'create'}
    {$title_action = $_L['Doctor_Add_Module']}
    {if (!empty($doctor))}
        {$action = 'update'}
        {$title_action = $_L['Doctor_Edit_Module']}
    {/if}

    <form class="form-horizontal" method="post" action="{$_url}module_med_scheduling/doctor/{$action}">

        <div class="row">

            <div class="col-md-12">

                <div class="ibox float-e-margins">

                    <div class="ibox-title">
                        <h5>{$title_action}</h5>
                        <a href="{$_url}module_med_scheduling/doctor/listDoctor"
                           class="btn btn-xs btn-primary btn-rounded pull-right">
                            <i class="fa fa-bars"></i> {$_L['Doctor_List']}
                        </a>
                    </div>

                    <div class="ibox-content" id="ibox_form">

                        <div class="row">

                            <div class="col-md-6 col-sm-12 col-xs-6">
                                {$name = ''}
                                {if (!empty($doctor->account))}
                                    {$name = $doctor->account}
                                {/if}
                                <label class="control-label" for="title">
                                    {$_L['Doctor_Name']} <small class="red">*</small>
                                </label>
                                <input type="text" name="account" id="account" class="form-control"
                                       value="{$name}" required>
                            </div>

                            <div class="col-md-6 col-sm-12 col-xs-6">
                                {$email = ''}
                                {if (!empty($doctor->email))}
                                    {$email = $doctor->email}
                                {/if}
                                <label class="control-label" for="title">
                                    {$_L['Doctor_Email']} <small class="red">*</small>
                                </label>
                                <input type="text" name="email" id="email" class="form-control"
                                       value="{$email}" required>
                            </div>

                        </div>

                        <div class="row">

                            <div class="col-md-6 col-sm-12 col-xs-6">
                                {$crm = ''}
                                {if (!empty($doctor->c1))}
                                    {$crm = $doctor->c1}
                                {/if}
                                <label class="control-label" for="title">
                                    {$_L['Doctor_Crm']} <small class="red">*</small>
                                </label>
                                <input type="text" name="c1" id="c1" class="form-control"
                                       value="{$crm}" required>
                            </div>

                            <div class="col-md-6 col-sm-12 col-xs-6">
                                {$crm_state = ''}
                                {if (!empty($doctor->c2))}
                                    {$crm_state = $doctor->c2}
                                {/if}
                                <label class="control-label" for="title">
                                    {$_L['Doctor_Crm_State']} <small class="red">*</small>
                                </label>
                                <select name="c2" id="c2" class="form-control state_select" required>
                                    {foreach $states as $s}
                                        <option value="{$s['id']}">{$s['state_name']}</option>
                                    {/foreach}
                                </select>
                            </div>

                        </div>

                        <div class="row">

                            <div class="col-md-12 col-sm-12 col-xs-12">
                                {$crm_obs = ''}
                                {if (!empty($doctor->crm_obs))}
                                    {$crm_obs = $doctor->crm_obs}
                                {/if}
                                <label class="control-label" for="title">
                                    {$_L['Doctor_Crm_Obs']}
                                </label>
                                <input type="text" name="crm_obs" id="crm_obs" class="form-control"
                                       value="{$crm_obs}">
                            </div>

                        </div>

                        <div class="row">

                            <div class="col-md-12 col-sm-12 col-xs-12">
                                {$signature = ''}
                                {if (!empty($doctor->signature))}
                                    {$signature = $doctor->signature}
                                {/if}
                                <label class="control-label" for="title">
                                    {$_L['Doctor_Signature']}
                                </label>

                                <div action="" class="dropzone dz-clickable drp_small" id="upload_container_signature">
                                    <div class="dz-message">
                                        <h3> <i class="fa fa-cloud-upload"></i>{$_L['Scheduling_Agreement_Guide_Upload']}</h3>
                                        <br>
                                        <span class="note">{$_L['Or Click to Upload']}</span>
                                    </div>
                                </div>
                                <input type="hidden" name="signature" id="signature" value="">

                            </div>

                        </div>

                        <div class="row">

                            <div class="col-md-6 col-sm-12 col-xs-6">
                                <label class="control-label" for="title">
                                    {$_L['Doctor_Password']}
                                    {if (empty($doctor->password))}<small class="red">*</small>{/if}
                                </label>
                                <input type="password" name="password" id="password" class="form-control"
                                       value="">

                                {if (!empty($doctor->password))}
                                    <span class="help-block">{$_L['password_change_help']}</span>
                                {/if}
                            </div>

                            <div class="col-md-6 col-sm-12 col-xs-6">
                                <label class="control-label" for="title">
                                    {$_L['Doctor_Password_Confirm']}
                                    {if (empty($doctor->password))}<small class="red">*</small>{/if}
                                </label>
                                <input type="password" name="cpassword" id="cpassword" class="form-control"
                                       value="">
                            </div>

                        </div>

                        <div class="row">

                            <div class="col-md-12 col-sm-12 col-xs-12">
                                {$phone = ''}
                                {if (!empty($doctor->phone))}
                                    {$phone = $doctor->phone}
                                {/if}
                                <label class="control-label" for="title">
                                    {$_L['Doctor_Phone']}
                                </label>
                                <input type="text" name="phone" id="phone" class="form-control fone"
                                       value="{$phone}">
                            </div>

                        </div>

                        <div class="row">

                            <div class="col-md-12 col-sm-12 col-xs-12">
                                {$cell_phone = ''}
                                {if (!empty($doctor->cell_phone))}
                                    {$cell_phone = $doctor->cell_phone}
                                {/if}
                                <label class="control-label" for="title">
                                    {$_L['Doctor_Cell_Phone']}
                                </label>
                                <input type="text" name="cell_phone" id="cell_phone" class="form-control fone"
                                       value="{$cell_phone}">
                            </div>

                        </div>

                        <div class="row" style="margin-top:20px">
                            <div class=" col-md-12 form-group">
                                <div class="col-lg-10">
                                    {if !empty($doctor->id)}
                                        <input type="hidden" id="doctorId" name="id" value="{$doctor->id}">
                                    {/if}
                                    <button class="md-btn md-btn-primary waves-effect waves-light" type="submit" id="submit">
                                        <i class="fa fa-check"></i> {$_L['Submit']}
                                    </button>
                                    | <a href="{$_url}module_med_scheduling/doctor/listDoctor">{$_L['Or Cancel']}</a>
                                </div>
                            </div>
                        </div>

                    </div>

                </div>

            </div>

        </div>

    </form>

</div>