@extends('themes.backend.layouts.app') @section('page_title') {{ $pageDataAtrArr['title'] }} @endsection @section('breadcrumb') {{ Breadcrumbs::render('new-patient-form.edit', $submission) }} @endsection @push('styles') @endpush @section('content')
@include('themes.backend.partials.module_title_breadcrumb', [ 'module_name' => $pageDataAtrArr['module_name'], ])
@include('themes.backend.partials.page_title', [ 'title' => $pageDataAtrArr['title'], ])
@if ($errors->any())
Please correct the highlighted fields and try again.
@endif @php $patientLabelClass = 'np-label'; $fieldsById = $form->fields->keyBy('id'); $requestFieldName = fn($field) => \App\Utilities\EnquiryUtility::getFieldRequestKey($form, $field); $fieldValue = fn($name, $default = '') => old($name, $fieldValues[$name] ?? $default); $radioChecked = fn($name, $value) => (string) $fieldValue($name) === (string) $value ? 'checked' : ''; $checkboxChecked = function ($name, $value) use ($fieldValue) { $rawValue = $fieldValue($name); $values = is_array($rawValue) ? $rawValue : array_map('trim', explode(',', (string) $rawValue)); return in_array((string) $value, array_map('strval', $values), true) ? 'checked' : ''; }; $optionValues = fn($field) => \App\Lib\Core\Core::parseJson($field->options) ?? []; $signatureFileName = $fieldValue('signature'); $signatureUrl = $signatureFileName ? $mediaFolder . $signatureFileName : ''; $patientTextFields = [ ['key' => 'date_of_birth', 'col' => 'np-col-4', 'type' => 'date'], ['key' => 'street_address', 'col' => 'np-col-8', 'type' => 'text'], ['key' => 'city', 'col' => 'np-col-4', 'type' => 'text'], ['key' => 'province', 'col' => 'np-col-4', 'type' => 'text'], ['key' => 'postal_code', 'col' => 'np-col-4', 'type' => 'text'], ['key' => 'email_address', 'col' => 'np-col-4', 'type' => 'email'], ['key' => 'home_phone', 'col' => 'np-col-6', 'type' => 'tel'], ['key' => 'cell_phone', 'col' => 'np-col-6', 'type' => 'tel'], ['key' => 'cccupation', 'col' => 'np-col-6', 'type' => 'text'], ['key' => 'employed_by', 'col' => 'np-col-6', 'type' => 'text'], ]; $insuranceFields = [ ['key' => 'insurance_company', 'col' => 'np-col-4', 'type' => 'text'], ['key' => 'policy_no', 'col' => 'np-col-4', 'type' => 'text'], ['key' => 'certificate_no', 'col' => 'np-col-4', 'type' => 'text'], ['key' => 'family_physician', 'col' => 'np-col-6', 'type' => 'text'], ['key' => 'physician_phone', 'col' => 'np-col-6', 'type' => 'tel'], ['key' => 'previous_dentist', 'col' => 'np-col-6', 'type' => 'text'], ['key' => 'previous_dentist_phone', 'col' => 'np-col-6', 'type' => 'tel'], ['key' => 'referral_credit', 'col' => 'np-col-12', 'type' => 'text'], ]; $emergencyFields = ['en_contact_name', 'en_relationship', 'en_address', 'en_phone_number']; $medicalRows = [ ['id' => 53, 'type' => 'date'], ['id' => 54, 'extra' => 'cup_care_specify'], ['id' => 56], ['id' => 57], ['id' => 58, 'extra' => 'drink_alcohol_specify'], ['id' => 60], ['id' => 61, 'extra' => 'herbal_substances_specify'], ['id' => 63, 'extra' => 'any_medications_specify'], ['id' => 65, 'extra' => 'prolonged_medication_specify'], ['id' => 67], ['id' => 68, 'extra' => 'any_surgery_specify'], ['id' => 70], ['id' => 71], ['id' => 72, 'extra' => 'pregnant_weeks'], ]; $medicalDrugReactionRows = [['id' => 76, 'extra' => 'adverse_reactions_specify']]; $medicalPostConditionRows = [ ['id' => 79], ['id' => 80, 'extra' => 'anything_else_know_specify'], ['id' => 82], ['id' => 83, 'extra' => 'anything_about_health_specify'], ['id' => 85], ]; $dentalRows = [ ['id' => 86, 'type' => 'date'], ['id' => 87, 'type' => 'date'], ['id' => 88, 'type' => 'date'], ['id' => 89], ['id' => 90, 'type' => 'text'], ['id' => 91, 'type' => 'text'], ['id' => 92], ['id' => 93], ['id' => 94], ['id' => 95], ['id' => 96], ['id' => 97, 'type' => 'text'], ['id' => 98, 'type' => 'text'], ['id' => 99, 'type' => 'text'], ['id' => 100, 'extra' => 'any_discomfort_specify'], ]; $dentalFollowUpRows = [ ['id' => 103], ['id' => 104], ['id' => 105], ['id' => 106], ['id' => 107], ['id' => 108], ['id' => 109], ['id' => 110], ['id' => 111], ['id' => 112], ]; $medicalReactionCheckboxGroups = [ ['field' => $fieldsById->get(74), 'cols' => 'cols-4'], ['field' => $fieldsById->get(75), 'cols' => 'cols-3'], ]; $medicalConditionCheckboxGroups = [ ['field' => $fieldsById->get(78), 'cols' => 'cols-3'], ]; $dentalCheckboxGroups = [['field' => $fieldsById->get(102), 'cols' => 'cols-3']]; @endphp

{{ $locationModel->title }}

{!! nl2br(e($locationModel->address)) !!}

{{ $locationModel->email }}

{{ $locationModel->phone }}

{{ csrf_field() }}
CHAGGER DENTAL PATIENT INFORMATION
@foreach ($arrayValues['title'] as $value => $label) @endforeach
@error($fields['title']->field_name) {{ $message }} @enderror
@error($fields['full_name']->field_name) {{ $message }} @enderror
@error($fields['age']->field_name) {{ $message }} @enderror
@foreach (['sex', 'marital_status'] as $fieldKey)
@foreach ($arrayValues[$fieldKey] as $value => $label) @endforeach
@error($fields[$fieldKey]->field_name) {{ $message }} @enderror
@endforeach @foreach ($patientTextFields as $fieldConfig) @php($field = $fields[$fieldConfig['key']])
@error($field->field_name) {{ $message }} @enderror
@endforeach
{{ $fields['dental_insurance']->field_label }}
@foreach ($arrayValues['dental_insurance'] as $value => $label) @endforeach
@error($fields['dental_insurance']->field_name) {{ $message }} @enderror
@foreach ($insuranceFields as $fieldConfig) @php($field = $fields[$fieldConfig['key']])
@error($field->field_name) {{ $message }} @enderror
@endforeach

In case of Emergency Notify:

@foreach ($emergencyFields as $fieldKey) @php($field = $fields[$fieldKey])
@error($field->field_name) {{ $message }} @enderror
@endforeach

OFFICE POLICY

We require at least 48 hours notice for any appointment cancellations or rescheduling. This allows us to offer the time to other patients who may need urgent care. A fee may be charged for missed appointments without sufficient notice.

Payment is required at the time of service. We accept major credit cards, debit, and cash. We will gladly help you process your insurance claims.

CONFIDENTIAL MEDICAL HISTORY
@foreach ($medicalRows as $fieldConfig) @php($field = $fieldsById->get($fieldConfig['id'])) @php($fieldRequestName = $requestFieldName($field)) @php($fieldOptions = $optionValues($field))

{!! $field->field_label !!}

@if ($field->type === 'radio')
@foreach ($fieldOptions as $value => $label) @endforeach
@else
@endif @isset($fieldConfig['extra']) @php($extraField = $fields[$fieldConfig['extra']]) @php($extraFieldRequestName = $requestFieldName($extraField)) @endisset @error($fieldRequestName) {{ $message }} @enderror
@endforeach @foreach ($medicalReactionCheckboxGroups as $group) @php($field = $group['field']) @if ($field) @php($fieldRequestName = $requestFieldName($field)) @php($options = $optionValues($field))

{!! $field->field_label !!}

@foreach ($options as $value => $label) @endforeach
@error($fieldRequestName) {{ $message }} @enderror
@endif @endforeach @foreach ($medicalDrugReactionRows as $fieldConfig) @php($field = $fieldsById->get($fieldConfig['id'])) @php($fieldRequestName = $requestFieldName($field)) @php($fieldOptions = $optionValues($field))

{!! $field->field_label !!}

@foreach ($fieldOptions as $value => $label) @endforeach
@php($extraField = $fields[$fieldConfig['extra']]) @php($extraFieldRequestName = $requestFieldName($extraField)) @error($fieldRequestName) {{ $message }} @enderror
@endforeach @foreach ($medicalConditionCheckboxGroups as $group) @php($field = $group['field']) @if ($field) @php($fieldRequestName = $requestFieldName($field)) @php($options = $optionValues($field))

{!! $field->field_label !!}

@foreach ($options as $value => $label) @endforeach
@error($fieldRequestName) {{ $message }} @enderror
@endif @endforeach @foreach ($medicalPostConditionRows as $fieldConfig) @php($field = $fieldsById->get($fieldConfig['id'])) @php($fieldRequestName = $requestFieldName($field)) @php($fieldOptions = $optionValues($field))

{!! $field->field_label !!}

@foreach ($fieldOptions as $value => $label) @endforeach
@isset($fieldConfig['extra']) @php($extraField = $fields[$fieldConfig['extra']]) @php($extraFieldRequestName = $requestFieldName($extraField)) @endisset @error($fieldRequestName) {{ $message }} @enderror
@endforeach
CONFIDENTIAL DENTAL HISTORY
@foreach ($dentalRows as $fieldConfig) @php($field = $fieldsById->get($fieldConfig['id'])) @php($fieldRequestName = $requestFieldName($field)) @php($fieldOptions = $optionValues($field))

{!! $field->field_label !!}

@if ($field->type === 'radio')
@foreach ($fieldOptions as $value => $label) @endforeach
@else
@endif @isset($fieldConfig['extra']) @php($extraField = $fields[$fieldConfig['extra']]) @php($extraFieldRequestName = $requestFieldName($extraField)) @endisset @error($fieldRequestName) {{ $message }} @enderror
@endforeach @foreach ($dentalCheckboxGroups as $group) @php($field = $group['field']) @if ($field) @php($fieldRequestName = $requestFieldName($field)) @php($options = $optionValues($field))

{!! $field->field_label !!}

@foreach ($options as $value => $label) @endforeach
@error($fieldRequestName) {{ $message }} @enderror
@endif @endforeach @foreach ($dentalFollowUpRows as $fieldConfig) @php($field = $fieldsById->get($fieldConfig['id'])) @php($fieldRequestName = $requestFieldName($field)) @php($fieldOptions = $optionValues($field))

{!! $field->field_label !!}

@foreach ($fieldOptions as $value => $label) @endforeach
@error($fieldRequestName) {{ $message }} @enderror
@endforeach
@error($fields['describe']->field_name) {{ $message }} @enderror
PATIENT CONSENT

This is to certify that I, the undersigned, consent to the performing of the dental procedures agreed to be necessary or advisable including the use of local anesthetic as indicated and I will assume responsibility for fees associated with those procedures.

Attached to this consent form, we have outlined what our office is doing to ensure that:

  • Only necessary information is collected about you
  • We only share your information with your consent
  • Storage, retention and destruction of your personal information complies with existing legislation and privacy protection protocols
  • Our privacy protocols comply with privacy legislation, standards of our regulatory body, the Royal College of Dental Surgeons of Ontario, and the law.

In this office, DR. B. CHAGGER acts as the Privacy Information Officer.

I have reviewed the above information that explains how your office will use my personal information, and the steps your office is taking to protect my information.

I know that your office has a Privacy Code, and I can ask to see the code at any time.

@error($fields['consent_privacy_patient']->field_name) {{ $message }} @enderror
@error($fields['consent_newsletter']->field_name) {{ $message }} @enderror
@if ($signatureUrl) Patient signature @else No signature was uploaded. @endif
Stored patient signature is shown for review.
@error($fields['signature']->field_name) {{ $message }} @enderror
@error($fields['print_name']->field_name) {{ $message }} @enderror
{{ __('admin.cancel_txt') }}

Updating this record will save the edited patient information, regenerate the registration PDF, and automatically download updated PDF for admin records.

@endsection @push('scripts') @if (session('download_pdf_url')) @endif @endpush