{{-- HEADER FOR REGISTRATION --}} @include('partials.registrationHeader')
@csrf @method('post') {{-- FIRST PAGE --}}
PERSONAL INFORMATION
{{-- LAST NAME --}}
@if ($errors->has('last_name'))
{{ $errors->first('last_name') }}
@endif {{-- FIRST NAME --}}
@error('first_name') {{ $message }} @enderror {{-- MIDDLE NAME --}}
@error('middle_name') {{ $message }} @enderror {{-- SUFFIX --}}
@error('suffix') {{ $message }} @enderror {{-- DATE OF BIRTH --}}
@error('date_of_birth') {{ $message }} @enderror {{-- GENDER --}}
@error('gender') {{ $message }} @enderror {{-- MARITAL STATUS --}}
@error('marital_status') {{ $message }} @enderror {{-- HOME ADDRESS --}}
@error('home_address') {{ $message }} @enderror {{-- CONTACT NUMBER --}}
@error('contact_number') {{ $message }} @enderror {{-- EMAIL ADDRESS --}}
@error('email_address') {{ $message }} @enderror {{-- NEXT PAGE --}}
{{-- SECOND PAGE --}}
DENTAL INFORMATION & HISTORY
{{-- LAST DENTIST VISIT --}}
@error('last_dentist_visit') {{ $message }} @enderror {{-- HAD CAVITIES --}}

Have you ever had cavities?

Yes
No
@error('had_cavities') {{ $message }} @enderror {{-- HAVE TOOTH SENSITIVITY --}}

Have you experienced tooth sensitivity?

Yes
No
@error('have_tooth_sensitivity') {{ $message }} @enderror {{-- GRIND OR CLENCH TEETH --}}

Do you grind or clench your teeth?

Yes
No
@error('grind_or_clench_teeth') {{ $message }} @enderror {{-- HAD ORAL SURGERIES --}}

Have you had any oral surgeries?

Yes
No
@error('had_oral_surgeries') {{ $message }} @enderror {{-- HAD BRACES OR OTHER ORTHODONTIC TREATMENTS --}}

Have you ever had braces or other orthodontic treatments?

Yes
No
@error('had_braces_or_orthodontic_treatments') {{ $message }} @enderror {{-- HAVE GUM DISEASE --}}

Have you been diagnosed with gum disease (periodontitis)?

Yes
No
@error('have_gum_disease') {{ $message }} @enderror {{-- DO GUMS BLEED --}}

Do your gums bleed when you brush or floss?

Yes
No
@error('do_gums_bleed') {{ $message }} @enderror {{-- GUM RECESSION OR GUM GRAFTING --}}

Have you ever been treated for gum recession or gum grafting?

Yes
No
@error('gum_recession_or_gum_grafting') {{ $message }} @enderror {{-- LOST TEETH DUE TO DECAY OR INJURY --}}

Have you lost any teeth due to decay or injury?

Yes
No
@error('lost_teeth_due_to_decay_or_injury') {{ $message }} @enderror {{-- HAVE DENTAL IMPLANTS --}}

Have you received dental implants?

Yes
No
@error('have_dental_implants') {{ $message }} @enderror {{-- HAVE CROWNS, BRIDGES, OR DENTURES --}}

Do you have any crowns, bridges, or dentures?

Yes
No
@error('have_crowns_bridges_or_dentures') {{ $message }} @enderror {{-- BRUSH TEETH AT LEAST TWICE A DAY --}}

Do you brush your teeth at least twice a day?

Yes
No
@error('brush_teeth_at_least_twice_a_day') {{ $message }} @enderror {{-- FLOSS DAILY --}}

Do you floss daily?

Yes
No
@error('floss_daily') {{ $message }} @enderror {{-- TAKING MEDICATIONS --}}

Are you taking any medications that may affect your oral health or cause dry mouth?

Yes
No
@error('taking_medications') {{ $message }} @enderror {{-- CONSUME SUGARY OR ACIDIC FOODS --}}

Do you consume sugary or acidic foods/beverages frequently?

Yes
No
@error('consume_sugary_or_acidic_foods') {{ $message }} @enderror {{-- IS SMOKING --}}

Do you smoke or use tobacco products?

Yes
No
@error('is_smoking') {{ $message }} @enderror {{-- DRINK COFFEE, TEA, OR RED WINE --}}

Do you regularly drink coffee, tea, or red wine?

Yes
No
@error('drink_coffee_tea_or_red_wine') {{ $message }} @enderror {{-- MEDICAL CONDIITONS LIKE DIABETES --}}

Do you have any medical conditions that affect your dental health (e.g., diabetes)?

@error('medical_conditions') {{ $message }} @enderror {{-- ALLERGY --}}

Do you have any allergy?

@error('allergy') {{ $message }} @enderror {{-- PREVIOUS PAGE --}} {{-- NEXT PAGE --}}
{{-- THIRD PAGE --}}
CREATE ACCOUNT
{{-- USERNAME --}}
@error('username') {{ $message }} @enderror {{-- PASSWORD --}}
@error('password') {{ $message }} @enderror {{-- VERIFY PASSWORD --}}
@error('verify_password') {{ $message }} @enderror {{-- CHECKBOX FOR DATA COLLECTION --}}
I agree to Whise Smile Dental Clinic's collection of personal and dental information
@error('agree_data_collection') {{ $message }} @enderror {{-- CHECKBOX FOR USER AGREEMENT AND PRIVACY POLICY --}}
I have read and agree to Whise Smile Dental Clinic's user agreement and privacy policy
@error('agree_user_policy') {{ $message }} @enderror
{{-- PREVIOUS PAGE --}} {{-- SUBMIT BUTTON --}}