

		 {!! Form::open(array('url'=>'dsinisters', 'class'=>'form-horizontal','files' => true , 'parsley-validate'=>'','novalidate'=>' ')) !!}

	@if(Session::has('messagetext'))
	  
		   {!! Session::get('messagetext') !!}
	   
	@endif
	<ul class="parsley-error-list">
		@foreach($errors->all() as $error)
			<li>{{ $error }}</li>
		@endforeach
	</ul>		


<div class="col-md-12">
						<fieldset><legend> Dossiers maladies</legend>
									
									  <div class="form-group row  " >
										<label for="Compte" class=" control-label col-md-4 text-left"> Compte <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <select name='id_account' rows='5' id='id_account' class='select2 '   ></select> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Cie" class=" control-label col-md-4 text-left"> Cie <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='cie' id='cie' value='{{ $row['cie'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Police" class=" control-label col-md-4 text-left"> Police <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='police' id='police' value='{{ $row['police'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Nom" class=" control-label col-md-4 text-left"> Nom <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='adherent_last_name' id='adherent_last_name' value='{{ $row['adherent_last_name'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Prénom" class=" control-label col-md-4 text-left"> Prénom <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='adherent_first_name' id='adherent_first_name' value='{{ $row['adherent_first_name'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Matricule" class=" control-label col-md-4 text-left"> Matricule <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='matricule' id='matricule' value='{{ $row['matricule'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Nom patient" class=" control-label col-md-4 text-left"> Nom patient <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='patient_last_name' id='patient_last_name' value='{{ $row['patient_last_name'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Prénom patient" class=" control-label col-md-4 text-left"> Prénom patient <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='patient_first_name' id='patient_first_name' value='{{ $row['patient_first_name'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Lien" class=" control-label col-md-4 text-left"> Lien <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='relationship' id='relationship' value='{{ $row['relationship'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Date visite" class=" control-label col-md-4 text-left"> Date visite <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='visit_date' id='visit_date' value='{{ $row['visit_date'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Nature maladie" class=" control-label col-md-4 text-left"> Nature maladie <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='disease_nature' id='disease_nature' value='{{ $row['disease_nature'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Montant engagé" class=" control-label col-md-4 text-left"> Montant engagé <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='committed_amount' id='committed_amount' value='{{ $row['committed_amount'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Montant rembourssement" class=" control-label col-md-4 text-left"> Montant rembourssement <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='advanced_amount' id='advanced_amount' value='{{ $row['advanced_amount'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Date rembourssement" class=" control-label col-md-4 text-left"> Date rembourssement <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='advanced_date' id='advanced_date' value='{{ $row['advanced_date'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Etat" class=" control-label col-md-4 text-left"> Etat <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='state' id='state' value='{{ $row['state'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Observations" class=" control-label col-md-4 text-left"> Observations <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='comment' id='comment' value='{{ $row['comment'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Opérateur" class=" control-label col-md-4 text-left"> Opérateur <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='operator' id='operator' value='{{ $row['operator'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Date saisie" class=" control-label col-md-4 text-left"> Date saisie <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='create_date' id='create_date' value='{{ $row['create_date'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Date mise à jour" class=" control-label col-md-4 text-left"> Date mise à jour <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <textarea name='SSISDate' rows='5' id='SSISDate' class='form-control form-control-sm '  
				           >{{ $row['SSISDate'] }}</textarea> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> </fieldset>
			</div>
			
			

			<div style="clear:both"></div>	
				
					
				  <div class="form-group">
					<label class="col-sm-4 text-right">&nbsp;</label>
					<div class="col-sm-8">	
					<button type="submit" name="apply" class="btn btn-default btn-sm" ><i class="fa  fa-check-circle"></i> {{ Lang::get('core.sb_apply') }}</button>
					<button type="submit" name="submit" class="btn btn-default btn-sm" ><i class="fa  fa-save "></i> {{ Lang::get('core.sb_save') }}</button>
				  </div>	  
			
		</div> 
		 <input type="hidden" name="action_task" value="public" />
		 {!! Form::close() !!}
		 
   <script type="text/javascript">
	$(document).ready(function() { 
		
		
		$("#id_account").jCombo("{!! url('dsinisters/comboselect?filter=sc_accounts:id:name') !!}",
		{  selected_value : '{{ $row["id_account"] }}' });
		 

		$('.removeCurrentFiles').on('click',function(){
			var removeUrl = $(this).attr('href');
			$.get(removeUrl,function(response){});
			$(this).parent('div').empty();	
			return false;
		});		
		
	});
	</script>		 
