98 lines
4.5 KiB
PHP
98 lines
4.5 KiB
PHP
<div class="mx-auto">
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<div class="mb-8">
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<flux:heading size="xl">Lengkapi Profil Pasien</flux:heading>
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<flux:subheading>Mohon lengkapi data medis Anda untuk mendapatkan layanan kesehatan kami.</flux:subheading>
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</div>
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<form wire:submit="save" class="space-y-8">
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{{-- Seksi Identitas Dasar --}}
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<section class="space-y-4">
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<flux:heading variant="subtle" class="uppercase tracking-wider">Informasi Identitas</flux:heading>
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<flux:separator variant="subtle" />
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<div class="gap-4 grid grid-cols-1 md:grid-cols-2">
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<flux:input wire:model="nik" label="NIK (Sesuai KTP)" placeholder="16 digit angka"
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mask="9999999999999999" />
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<div class="gap-4 grid grid-cols-2">
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<flux:select wire:model="gender" label="Jenis Kelamin">
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<option value="">Pilih...</option>
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<option value="L">Laki-laki</option>
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<option value="P">Perempuan</option>
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</flux:select>
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<flux:select wire:model="blood_type" label="Golongan Darah">
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<option value="">Pilih...</option>
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<option value="A">A</option>
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<option value="B">B</option>
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<option value="AB">AB</option>
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<option value="O">O</option>
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<option value="-">-</option>
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</flux:select>
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</div>
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</div>
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<div class="gap-4 grid grid-cols-1 md:grid-cols-2">
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<flux:input wire:model="place_of_birth" label="Tempat Lahir" placeholder="Contoh: Jakarta" />
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<flux:input wire:model="date_of_birth" type="date" label="Tanggal Lahir" />
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</div>
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</section>
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{{-- Seksi Kontak --}}
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<section class="space-y-4">
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<flux:heading variant="subtle" class="uppercase tracking-wider">Informasi Kontak</flux:heading>
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<flux:separator variant="subtle" />
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<flux:input wire:model="phone" label="Nomor Telepon/WhatsApp" icon="phone" placeholder="0812xxxx" />
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<flux:textarea wire:model="address" label="Alamat Domisili Sekarang"
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placeholder="Tuliskan alamat lengkap beserta kode pos..." />
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</section>
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{{-- Seksi Kontak Darurat --}}
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<section
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class="space-y-4 bg-zinc-50 dark:bg-white/5 p-4 border border-zinc-200 dark:border-white/10 rounded-xl">
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<flux:heading variant="subtle" class="uppercase tracking-wider">Kontak Darurat (Opsional)</flux:heading>
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<div class="gap-4 grid grid-cols-1 md:grid-cols-3">
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<flux:input wire:model="emergency_contact_name" label="Nama Lengkap" />
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<flux:input wire:model="emergency_contact_relation" label="Hubungan"
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placeholder="Misal: Istri, Ayah, dll" />
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<flux:input wire:model="emergency_contact_phone" label="No. Telepon" />
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</div>
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</section>
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{{-- Letakkan setelah Seksi Kontak --}}
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<section class="space-y-4">
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<flux:heading variant="subtle" class="uppercase tracking-wider">Metode Pembayaran / Penjamin</flux:heading>
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<flux:separator variant="subtle" />
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<div class="items-start gap-6 grid grid-cols-1 md:grid-cols-2">
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{{-- Pilihan Jenis Penjamin --}}
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<flux:field>
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<flux:label>Jenis Penjaminan</flux:label>
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<flux:select wire:model.live="insurance_type">
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<option value="Umum">Umum (Mandiri)</option>
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<option value="BPJS">BPJS Kesehatan</option>
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<option value="Asuransi Swasta">Asuransi Swasta</option>
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</flux:select>
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</flux:field>
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{{-- Input Nomor Kartu (Hanya muncul jika bukan Umum) --}}
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@if ($insurance_type !== 'Umum')
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<flux:field transition>
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<flux:input wire:model="insurance_number" label="Nomor Kartu {{ $insurance_type }}"
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placeholder="Masukkan nomor kartu peserta..." />
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<flux:error name="insurance_number" />
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</flux:field>
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@endif
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</div>
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</section>
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<div class="flex justify-end gap-3">
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<flux:button type="submit" variant="primary" class="px-8">
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Simpan Profil & Lanjutkan
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</flux:button>
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</div>
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</form>
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</div>
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