{{ Form::label('name', __('messages.insurance.insurance').(':'), ['class' => 'form-label fs-6 fw-bolder text-gray-700 mb-3']) }} {{ Form::text('name', null, ['class' => 'form-control form-control-solid', 'required']) }}

{{ Form::label('service_tax', __('messages.insurance.service_tax').(':'), ['class' => 'form-label fs-6 fw-bolder text-gray-700 mb-3']) }} {{ Form::text('service_tax', null, ['class' => 'form-control form-control-solid service-tax price-input', 'required']) }}

{{ Form::label('discount', __('messages.insurance.discount').(': '), ['class' => 'form-label fs-6 fw-bolder text-gray-700 mb-3']) }} (In percentage (%)) {{ Form::number('discount', null, ['id'=>'discountId','class' => 'form-control form-control-solid discount', 'min' => 0, 'max' => 100, 'step' => '.01']) }}

{{ Form::label('insurance_no', __('messages.insurance.insurance_no').(':'), ['class' => 'form-label fs-6 fw-bolder text-gray-700 mb-3']) }} {{ Form::text('insurance_no', null, ['class' => 'form-control form-control-solid', 'required']) }}

{{ Form::label('insurance_code', __('messages.insurance.insurance_code').(':'), ['class' => 'form-label fs-6 fw-bolder text-gray-700 mb-3']) }} {{ Form::text('insurance_code', null, ['class' => 'form-control form-control-solid', 'required']) }}

{{ Form::label('hospital_rate', __('messages.insurance.hospital_rate').(':'), ['class' => 'form-label fs-6 fw-bolder text-gray-700 mb-3']) }} {{ Form::text('hospital_rate', null, ['class' => 'form-control form-control-solid hospital-rate price-input', 'required']) }}

{{ Form::label('remark', __('messages.insurance.remark').(':'), ['class' => 'form-label fs-6 fw-bolder text-gray-700 mb-3']) }} {{ Form::textarea('remark', null, ['class' => 'form-control form-control-solid', 'rows' => 4]) }}

{{ Form::label('status', __('messages.common.status').(':'), ['class' => 'form-label fs-6 fw-bolder text-gray-700 mb-3']) }}

status) ? 'checked' : '')}}>

@if(isset($diseases)) @foreach($diseases as $disease) @endforeach @else @endif

#	{{ __('messages.insurance.diseases_name') }}	{{ __('messages.insurance.diseases_charge') }}
{{ $loop->iteration }}	{{ Form::text('disease_name[]', $disease->disease_name, ['class' => 'form-control disease-name form-control-solid','required']) }}	{{ Form::text('disease_charge[]', $disease->disease_charge, ['class' => 'form-control form-control-solid disease-charge form-control-solid price-input','required']) }}
1	{{ Form::text('disease_name[]', null, ['class' => 'form-control form-control-solid disease-name','required']) }}	{{ Form::text('disease_charge[]', null, ['class' => 'form-control form-control-solid disease-charge price-input','required']) }}

{{ getCurrencySymbol() }} {{ isset($insurance) ? number_format($insurance->total,2) : 0 }}

{{ Form::hidden('total', null, ['class' => 'form-control', 'id' => 'total_amount']) }}

{{ Form::submit(__('messages.common.save'), ['class' => 'btn btn-primary me-3', 'id'=>'saveBtn']) }} {{ __('messages.common.cancel') }}