{% extends "base.html" %}

{% block title %}{% if doctor %}Edit{% else %}New{% endif %} Doctor - Vera Medical CRM{% endblock %}

{% block content %}
<div class="mb-6">
    <h1 class="text-3xl font-bold text-gray-800">
        {% if doctor %}Edit Doctor{% else %}Add New Doctor{% endif %}
    </h1>
    <p class="text-gray-600">
        {% if doctor %}Update doctor information{% else %}Create a new doctor profile{% endif %}
    </p>
</div>

<div class="max-w-6xl">
    <form method="POST" class="bg-white rounded-lg shadow-md p-6 space-y-6">
        
        <!-- Name Section -->
        <div class="border-b pb-6">
            <h2 class="text-xl font-bold text-gray-800 mb-4">
                <i class="fas fa-user-md mr-2 text-blue-600"></i>Name
            </h2>
            <div class="grid grid-cols-1 md:grid-cols-3 gap-4">
                <div>
                    <label class="block text-sm font-medium text-gray-700 mb-2">Prefix</label>
                    <select name="prefix" class="w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-blue-500">
                        <option value="">Select...</option>
                        <option value="Dr." {% if doctor and doctor['prefix'] == 'Dr.' %}selected{% endif %}>Dr.</option>
                        <option value="Mr." {% if doctor and doctor['prefix'] == 'Mr.' %}selected{% endif %}>Mr.</option>
                        <option value="Mrs." {% if doctor and doctor['prefix'] == 'Mrs.' %}selected{% endif %}>Mrs.</option>
                        <option value="Ms." {% if doctor and doctor['prefix'] == 'Ms.' %}selected{% endif %}>Ms.</option>
                    </select>
                </div>
                <div>
                    <label class="block text-sm font-medium text-gray-700 mb-2">First Name *</label>
                    <input type="text" name="first_name" required
                           value="{{ doctor['first_name'] if doctor else '' }}"
                           placeholder="David"
                           class="w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-blue-500">
                </div>
                <div>
                    <label class="block text-sm font-medium text-gray-700 mb-2">Last Name *</label>
                    <input type="text" name="last_name" required
                           value="{{ doctor['last_name'] if doctor else '' }}"
                           placeholder="Adams"
                           class="w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-blue-500">
                </div>
            </div>
        </div>
        
        <!-- Specialty -->
        <div class="border-b pb-6">
            <h2 class="text-xl font-bold text-gray-800 mb-4">
                <i class="fas fa-stethoscope mr-2 text-green-600"></i>Specialty
            </h2>
            <div class="grid grid-cols-1 md:grid-cols-2 gap-4">
                <div class="md:col-span-2">
                    <label class="block text-sm font-medium text-gray-700 mb-2">Specialty</label>
                    <input type="text" name="specialty"
                           value="{{ doctor['specialty'] if doctor else '' }}"
                           placeholder="e.g. General Surgeon, Psychologist"
                           class="w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-blue-500">
                </div>
            </div>
        </div>
        
        <!-- Mailing Address -->
        <div class="border-b pb-6">
            <h2 class="text-xl font-bold text-gray-800 mb-4">
                <i class="fas fa-envelope mr-2 text-purple-600"></i>Mailing Address
            </h2>
            <div class="grid grid-cols-1 md:grid-cols-2 gap-4">
                <div class="md:col-span-2">
                    <label class="block text-sm font-medium text-gray-700 mb-2">Address</label>
                    <input type="text" name="mailing_address"
                           value="{{ doctor['mailing_address'] if doctor else '' }}"
                           placeholder="Street address"
                           class="w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-blue-500">
                </div>
                <div>
                    <label class="block text-sm font-medium text-gray-700 mb-2">City</label>
                    <input type="text" name="mailing_city"
                           value="{{ doctor['mailing_city'] if doctor else '' }}"
                           placeholder="Edmonton"
                           class="w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-blue-500">
                </div>
                <div>
                    <label class="block text-sm font-medium text-gray-700 mb-2">Province</label>
                    <input type="text" name="mailing_province"
                           value="{{ doctor['mailing_province'] if doctor else '' }}"
                           placeholder="AB"
                           class="w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-blue-500">
                </div>
                <div>
                    <label class="block text-sm font-medium text-gray-700 mb-2">Postal Code</label>
                    <input type="text" name="mailing_postal_code"
                           value="{{ doctor['mailing_postal_code'] if doctor else '' }}"
                           placeholder="T5J 3B4"
                           class="w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-blue-500">
                </div>
            </div>
        </div>
        
        <!-- Contact Information -->
        <div class="border-b pb-6">
            <h2 class="text-xl font-bold text-gray-800 mb-4">
                <i class="fas fa-phone mr-2 text-orange-600"></i>Contact Information
            </h2>
            <div class="grid grid-cols-1 md:grid-cols-2 gap-4">
                <div>
                    <label class="block text-sm font-medium text-gray-700 mb-2">Phone</label>
                    <input type="tel" name="phone"
                           value="{{ doctor['phone'] if doctor else '' }}"
                           placeholder="(780) 903-8733"
                           class="w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-blue-500">
                </div>
                <div>
                    <label class="block text-sm font-medium text-gray-700 mb-2">Cell Phone</label>
                    <input type="tel" name="cell_phone"
                           value="{{ doctor['cell_phone'] if doctor else '' }}"
                           placeholder="(780) 903-8733"
                           class="w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-blue-500">
                </div>
                <div class="md:col-span-2">
                    <label class="block text-sm font-medium text-gray-700 mb-2">Email</label>
                    <input type="email" name="email"
                           value="{{ doctor['email'] if doctor else '' }}"
                           placeholder="doctor@example.com"
                           class="w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-blue-500">
                </div>
            </div>
        </div>
        
        <!-- Clinic Address -->
        <div class="border-b pb-6">
            <h2 class="text-xl font-bold text-gray-800 mb-4">
                <i class="fas fa-hospital mr-2 text-red-600"></i>Clinic Address
            </h2>
            <div class="grid grid-cols-1 md:grid-cols-2 gap-4">
                <div class="md:col-span-2">
                    <label class="block text-sm font-medium text-gray-700 mb-2">Clinic Address</label>
                    <input type="text" name="clinic_address"
                           value="{{ doctor['clinic_address'] if doctor else '' }}"
                           placeholder="Street address"
                           class="w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-blue-500">
                </div>
                <div>
                    <label class="block text-sm font-medium text-gray-700 mb-2">City</label>
                    <input type="text" name="clinic_city"
                           value="{{ doctor['clinic_city'] if doctor else '' }}"
                           placeholder="Edmonton"
                           class="w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-blue-500">
                </div>
                <div>
                    <label class="block text-sm font-medium text-gray-700 mb-2">Province</label>
                    <input type="text" name="clinic_province"
                           value="{{ doctor['clinic_province'] if doctor else '' }}"
                           placeholder="AB"
                           class="w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-blue-500">
                </div>
                <div>
                    <label class="block text-sm font-medium text-gray-700 mb-2">Postal Code</label>
                    <input type="text" name="clinic_postal_code"
                           value="{{ doctor['clinic_postal_code'] if doctor else '' }}"
                           placeholder="T5J 3B4"
                           class="w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-blue-500">
                </div>
            </div>
        </div>
        
        <!-- Additional Information -->
        <div class="border-b pb-6">
            <h2 class="text-xl font-bold text-gray-800 mb-4">
                <i class="fas fa-info-circle mr-2 text-yellow-600"></i>Additional Information
            </h2>
            <div class="grid grid-cols-1 md:grid-cols-2 gap-4">
                <div>
                    <label class="block text-sm font-medium text-gray-700 mb-2">Cancellation Fee</label>
                    <input type="text" name="cancellation_fee"
                           value="{{ doctor['cancellation_fee'] if doctor else '' }}"
                           placeholder="e.g. $150"
                           class="w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-blue-500">
                </div>
                <div class="md:col-span-2">
                    <label class="block text-sm font-medium text-gray-700 mb-2">Notes</label>
                    <textarea name="notes" rows="4"
                              placeholder="Additional notes or comments..."
                              class="w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-blue-500">{{ doctor['notes'] if doctor else '' }}</textarea>
                </div>
            </div>
        </div>

        <!-- Phase 4: Doctor Fees -->
        <div class="border-b pb-6">
            <h2 class="text-xl font-bold text-gray-800 mb-4">
                <i class="fas fa-dollar-sign mr-2 text-green-600"></i>Provider Fees
            </h2>
            <div class="grid grid-cols-1 md:grid-cols-3 gap-4">
                <div>
                    <label class="block text-sm font-medium text-gray-700 mb-2">Provider Fee (CAD $)</label>
                    <input type="number" 
                           name="provider_fee" 
                           step="0.01" 
                           min="0"
                           value="{% if doctor and doctor.get('provider_fee') %}{{ "%.2f"|format(doctor['provider_fee']) }}{% endif %}"
                           placeholder="0.00"
                           class="w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-blue-500">
                    <p class="text-xs text-gray-500 mt-1">Standard provider fee</p>
                </div>
                <div>
                    <label class="block text-sm font-medium text-gray-700 mb-2">Trial Fee Per Hour (CAD $)</label>
                    <input type="number" 
                           name="trial_fee_per_hour" 
                           step="0.01" 
                           min="0"
                           value="{% if doctor and doctor.get('trial_fee_per_hour') %}{{ "%.2f"|format(doctor['trial_fee_per_hour']) }}{% endif %}"
                           placeholder="0.00"
                           class="w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-blue-500">
                    <p class="text-xs text-gray-500 mt-1">Hourly rate for trial prep</p>
                </div>
                <div>
                    <label class="block text-sm font-medium text-gray-700 mb-2">Trial Fee Template</label>
                    <input type="text" 
                           name="trial_fee_template"
                           value="{% if doctor and doctor.get('trial_fee_template') %}{{ doctor['trial_fee_template'] }}{% endif %}"
                           placeholder="Template reference"
                           class="w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-blue-500">
                    <p class="text-xs text-gray-500 mt-1">Reference to fee template</p>
                </div>
            </div>
        </div>

        <!-- Form Actions -->
        <div class="flex justify-end space-x-4 pt-4 border-t">
            <a href="{{ url_for('doctors_list') }}" 
               class="px-6 py-2 border border-gray-300 text-gray-700 rounded-lg hover:bg-gray-50 transition">
                Cancel
            </a>
            <button type="submit" 
                    class="px-6 py-2 bg-blue-600 hover:bg-blue-700 text-white rounded-lg font-semibold transition">
                <i class="fas fa-save mr-2"></i>
                {% if doctor %}Update{% else %}Create{% endif %} Doctor
            </button>
        </div>
    </form>
</div>
{% endblock %}