{{ header }}
<div class="bg-white">
  <div class="breadcrumb-container">
    <div class="container">
    <div class="row">
    <div class="col-sm-12 col-md-5 col-lg-4">
        <h3 class="home-title">{{ heading_title }}</h3>
      </div>
      </div>
      </div>
  </div>
<div id="account-return" class="container">
  <div class="row row-responsive">{{ column_left }}
    <div id="content" class="col">{{ content_top }}
      <h2>{{ heading_title }}</h2>
      <p>{{ text_description }}</p>
      <form id="form-return" action="{{ save }}" method="post" data-oc-toggle="ajax">
        <fieldset>
          <legend>{{ text_order }}</legend>
          <div class="row mb-3 required">
           
            <div class="col-sm-12 form-floating">
              <input type="text" name="firstname" value="{{ firstname }}" placeholder="{{ entry_firstname }}" id="input-firstname" class="form-control"/>
               <label for="input-firstname" class="col-sm-2 col-form-label">{{ entry_firstname }}</label>
              <div id="error-firstname" class="invalid-feedback"></div>
            </div>
          </div>
          <div class="row mb-3 required">
            
            <div class="col-sm-12 form-floating">
              <input type="text" name="lastname" value="{{ lastname }}" placeholder="{{ entry_lastname }}" id="input-lastname" class="form-control"/>
              <label for="input-lastname" class="col-sm-2 col-form-label">{{ entry_lastname }}</label>
              <div id="error-lastname" class="invalid-feedback"></div>
            </div>
          </div>
          <div class="row mb-3 required">
            
            <div class="col-sm-12 form-floating">
              <input type="text" name="email" value="{{ email }}" placeholder="{{ entry_email }}" id="input-email" class="form-control"/>
              <label for="input-email" class="col-sm-2 col-form-label">{{ entry_email }}</label>
              <div id="error-email" class="invalid-feedback"></div>
            </div>
          </div>
          <div class="row mb-3 required">
            
            <div class="col-sm-12 form-floating">
              <input type="text" name="telephone" value="{{ telephone }}" placeholder="{{ entry_telephone }}" id="input-telephone" class="form-control"/>
              <label for="input-telephone" class="col-sm-2 col-form-label">{{ entry_telephone }}</label>
              <div id="error-telephone" class="invalid-feedback"></div>
            </div>
          </div>
          <div class="row mb-3 required">
            
            <div class="col-sm-12 form-floating">
              <input type="text" name="order_id" value="{{ order_id }}" placeholder="{{ entry_order_id }}" id="input-order-id" class="form-control"/>
              <label for="input-order-id" class="col-sm-2 col-form-label">{{ entry_order_id }}</label>
              <div id="error-order-id" class="invalid-feedback"></div>
            </div>
          </div>
          <div class="row mb-3 required">
            <div class="col-sm-12 form-floating">
              <label for="input-date-ordered" class="col-sm-12 col-form-label">{{ entry_date_ordered }}</label>
              <div class="col-sm-12 col-md-4">
                <div class="input-group">
                  <input type="text" name="date_ordered" value="{{ date_ordered }}" placeholder="{{ entry_date_ordered }}" id="input-date-ordered" class="form-control date"/>
                  <div class="input-group-text btn-default"><i class="fa-regular fa-calendar"></i></div>
                </div>
              </div>
            </div>
          </div>
        </fieldset>
        <fieldset>
          <legend>{{ text_product }}</legend>
          <div class="row mb-3 required">
            
            <div class="col-sm-12 form-floating">
              <input type="text" name="product" value="{{ product }}" placeholder="{{ entry_product }}" id="input-product" class="form-control"/> <input type="hidden" name="product_id" value="{{ product_id }}"/>
              <label for="input-product" class="col-sm-2 col-form-label">{{ entry_product }}</label>
              <div id="error-product" class="invalid-feedback"></div>
            </div>
          </div>
          <div class="row mb-3 required">
            <div class="col-sm-12 form-floating">
              <input type="text" name="model" value="{{ model }}" placeholder="{{ entry_model }}" id="input-model" class="form-control"/>
              <label for="input-model" class="col-sm-2 col-form-label">{{ entry_model }}</label>
              <div id="error-model" class="invalid-feedback"></div>
            </div>
          </div>
          <div class="row mb-3 required">
            <div class="col-sm-12 form-floating">
              <input type="text" name="quantity" value="1" placeholder="{{ entry_quantity }}" id="input-quantity" class="form-control"/>
              <label for="input-quantity" class="col-sm-2 col-form-label">{{ entry_quantity }}</label>
            </div>
          </div>
          <div class="row required">
            <label class="col-sm-12 col-form-label">{{ entry_reason }}</label>
            <div class="col-sm-12 form-floating">
              <div id="input-reason">
                {% for return_reason in return_reasons %}
                  <div class="form-check">
                    <input type="radio" name="return_reason_id" value="{{ return_reason.return_reason_id }}" id="input-return-reason-{{ return_reason.return_reason_id }}" class="form-check-input"/> <label for="input-return-reason-{{ return_reason.return_reason_id }}" class="form-check-label">{{ return_reason.name }}</label>
                  </div>
                {% endfor %}
              </div>
              <div id="error-reason" class="invalid-feedback"></div>
            </div>
          </div>
          <div class="row required">
            <label class="col-sm-12 col-form-label">{{ entry_opened }}</label>
            <div class="col-sm-12 form-floating">
              <div class="form-check form-check-inline">
                <input type="radio" name="opened" value="1" id="input-opened-yes" class="form-check-input" checked/> <label for="input-opened-yes" class="form-check-label">{{ text_yes }}</label>
              </div>
              <div class="form-check form-check-inline">
                <input type="radio" name="opened" value="0" id="input-opened-no" class="form-check-input"/> <label for="input-opened-no" class="form-check-label">{{ text_no }}</label>
              </div>
            </div>
          </div>
          <div class="row mb-3 required">
            <label for="input-comment" class="col-sm-12 col-form-label">{{ entry_fault_detail }}</label>
            <div class="col-sm-12 form-floating">
              <textarea name="comment" rows="10" placeholder="{{ entry_fault_detail }}" id="input-comment" class="form-control form_detail"></textarea>
            </div>
          </div>
          {{ captcha }}
        </fieldset>
        <div class="d-inline-block pt-2 pd-2 w-100">
          <div class="float-start"><a href="{{ back }}" class="custom-btn btn btn-default">{{ button_back }}</a></div>
          <div class="float-end">
            {% if text_agree %}
              <div class="form-check form-check-inline">
                <label class="form-check-label">{{ text_agree }}</label> <input type="checkbox" name="agree" value="1" class="form-check-input"/>
                &nbsp;
              </div>
            {% endif %}
            <button type="submit" class="custom-btn btn btn-primary">{{ button_submit }}</button>
          </div>
        </div>
      </form>
      {{ content_bottom }}</div>
    {{ column_right }}</div>
</div>
</div>
{{ footer }}