{% extends "base.html" %} {% block title %}Edit Registration - Doctor Appeal{% endblock %} {% block content %}

Edit Registration & Submit Appeal

{{ form.hidden_tag() }}
Basic Information
{{ form.name.label(class="form-label") }} {{ form.name(class="form-control") }} {% if form.name.errors %}
{% for error in form.name.errors %}{{ error }}{% endfor %}
{% endif %}
{{ form.email.label(class="form-label") }} {{ form.email(class="form-control") }} {% if form.email.errors %}
{% for error in form.email.errors %}{{ error }}{% endfor %}
{% endif %}
{{ form.phone.label(class="form-label") }} {{ form.phone(class="form-control") }} {% if form.phone.errors %}
{% for error in form.phone.errors %}{{ error }}{% endfor %}
{% endif %}
{{ form.cnic.label(class="form-label") }} {{ form.cnic(class="form-control") }} {% if form.cnic.errors %}
{% for error in form.cnic.errors %}{{ error }}{% endfor %}
{% endif %} Enter 13-digit CNIC number (e.g., 1234512345671)
{{ form.date_of_birth.label(class="form-label") }} {{ form.date_of_birth(class="form-control") }} {% if form.date_of_birth.errors %}
{% for error in form.date_of_birth.errors %}{{ error }}{% endfor %}
{% endif %}
{{ form.gender.label(class="form-label") }} {{ form.gender(class="form-select") }} {% if form.gender.errors %}
{% for error in form.gender.errors %}{{ error }}{% endfor %}
{% endif %}
Professional Information
{{ form.category.label(class="form-label") }} {{ form.category(class="form-select") }} {% if form.category.errors %}
{% for error in form.category.errors %}{{ error }}{% endfor %}
{% endif %}
{{ form.specialization(class="form-control", id="specialization-input-edit", autocomplete="off", autofill="off") }}
{% if form.specialization.errors %}
{% for error in form.specialization.errors %}{{ error }}{% endfor %}
{% endif %} Start typing specialization to see suggestions
{{ form.experience.label(class="form-label") }} {{ form.experience(class="form-control") }} {% if form.experience.errors %}
{% for error in form.experience.errors %}{{ error }}{% endfor %}
{% endif %}
{{ form.pmc_code.label(class="form-label") }} {{ form.pmc_code(class="form-control") }} {% if form.pmc_code.errors %}
{% for error in form.pmc_code.errors %}{{ error }}{% endfor %}
{% endif %}
{{ form.education.label(class="form-label") }} {{ form.education(class="form-control", rows="3") }} {% if form.education.errors %}
{% for error in form.education.errors %}{{ error }}{% endfor %}
{% endif %}
{{ form.bio.label(class="form-label") }} {{ form.bio(class="form-control", rows="3") }} {% if form.bio.errors %}
{% for error in form.bio.errors %}{{ error }}{% endfor %}
{% endif %}
{{ form.city.label(class="form-label") }}
{{ form.city(class="form-control", id="city-input-edit", autocomplete="off", autofill="off") }}
{% if form.city.errors %}
{% for error in form.city.errors %}{{ error }}{% endfor %}
{% endif %} Start typing city name to see suggestions
{{ form.location.label(class="form-label") }} {{ form.location(class="form-control") }} {% if form.location.errors %}
{% for error in form.location.errors %}{{ error }}{% endfor %}
{% endif %}
Document Uploads

Your existing documents are shown below. Upload new files only if you want to replace them. Leave blank to keep existing documents.

{% if doctor.cnic_front_image %}
Current Image
CNIC Front
{% endif %}
{{ form.cnic_front(class="form-control", id="cnic-front-input", onchange="previewCNICFront(this)") }} {% if form.cnic_front.errors %}
{% for error in form.cnic_front.errors %}{{ error }}{% endfor %}
{% endif %}
{% if doctor.cnic_front_image %} Click "Remove" to replace with new image. Selected image will be shown in preview. {% else %} Upload CNIC front image. Preview will be shown after selection. {% endif %}
{% if doctor.cnic_back_image %}
Current Image
CNIC Back
{% endif %}
{{ form.cnic_back(class="form-control", id="cnic-back-input", onchange="previewCNICBack(this)") }} {% if form.cnic_back.errors %}
{% for error in form.cnic_back.errors %}{{ error }}{% endfor %}
{% endif %}
{% if doctor.cnic_back_image %} Click "Remove" to replace with new image. Selected image will be shown in preview. {% else %} Upload CNIC back image. Preview will be shown after selection. {% endif %}
{% if doctor.degree_documents and doctor.degree_documents|length > 0 %} {% for degree_doc in doctor.degree_documents %}
Document {{ loop.index }}
{% if degree_doc.endswith('.pdf') %}

PDF Document

View PDF {% else %} Degree {{ loop.index }} {% endif %}
{% endfor %} {% endif %} {% if not doctor.degree_documents or doctor.degree_documents|length == 0 %}
Upload Document
{% endif %}
Click to delete existing documents. Use to add more documents.
{% if doctor.live_photo %}
Current Photo
Live Photo
{% else %}

Click "Start Camera" to capture live photo

{{ form.live_photo_data() }}
{% endif %} {% if doctor.live_photo %} Click "Retake" to capture a new photo, or keep the current one. {% else %} Take a live photo for identity verification {% endif %}
{% endblock %} {% block extra_css %} {% endblock %} {% block extra_js %} {% endblock %}