{{ __('medical_reimbursement.title') }}

{{ __('medical_reimbursement.subtitle') }}

{{-- ========================= PATIENT DETAILS ========================= --}}

{{ __('medical_reimbursement.patient_section') }}

{{__('medical_reimbursement.patient_name')}} * @error('patient_name') {{ $message }} @enderror

{{__('medical_reimbursement.insurance_id')}} * @error('insurance_id') {{ $message }} @enderror

{{__('medical_reimbursement.emirates_id')}} * @error('emirates_id') {{ $message }} @enderror

{{__('medical_reimbursement.treatment_date')}} * @error('treatment_date') {{ $message }} @enderror

{{__('medical_reimbursement.treatment_place')}} * @error('treatment_place') {{ $message }} @enderror

{{__('medical_reimbursement.claim_amount')}} * @error('claim_amount') {{ $message }} @enderror

{{-- ========================= BANK DETAILS ========================= --}}

{{ __('medical_reimbursement.bank_section') }}

{{__('medical_reimbursement.bank_name')}} * @error('bank_name') {{ $message }} @enderror

{{__('medical_reimbursement.bank_emirates_id')}} * @error('bank_emirates_id') {{ $message }} @enderror

{{__('medical_reimbursement.account_no')}} * @error('account_no') {{ $message }} @enderror

{{__('medical_reimbursement.iban_no')}} * @error('iban_no') {{ $message }} @enderror

{{__('medical_reimbursement.principal_mobile')}} *

+971

@error('principal_mobile') {{ $message }} @enderror

{{__('medical_reimbursement.principal_email')}} * @error('principal_email') {{ $message }} @enderror

{{__('medical_reimbursement.documents')}} * @error('documents') {{ $message }} @enderror @error('documents.*') {{ $message }} @enderror

{{-- Message --}}

{{__('medical_reimbursement.message')}} * @error('message') {{ $message }} @enderror

{{-- Submit --}}

{{__('medical_reimbursement.submit')}} {{__('medical_reimbursement.processing')}}

{{-- Flash Messages --}} @if (session()->has('success')) @endif @if (session()->has('error')) @endif