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@@ -12,23 +12,12 @@
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</nav>
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</div>
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</div>
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-<div class="py-5">
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- <div class="container">
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+<div class="container py-5">
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<div class="row justify-content-center">
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- <div class="col-lg-7 text-center">
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- <h5 class="subtitle">Get In Touch</h5>
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+ <div class="col-lg-8 bg-grey p-lg-5 p-4" style="border-bottom:7px solid var(--pry-color);">
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+ <h5 class="subtitle mb-3">Get In Touch</h5>
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<p>If you have questions about the Snyder HemBand, our training program, or anything else, please contact us anytime. We’ll get back to you as soon as possible, typically within 1 business day.</p>
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- <p>If you are already a partner and need assistance, please contact one of the following departments:</p>
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- </div>
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- </div>
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- </div>
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-</div>
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-<div class="bg-light">
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- <div class="container py-5">
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- <div class="row justify-content-center">
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- <div class="col-lg-8 bg-grey p-lg-5 p-4">
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- <h5 class="header mb-4">Contact Us</h5>
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- <form class="" action="{{ route('physicians.submit-contact-us') }}" method="post" autocomplete="off">
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+ <form class="mt-4" action="{{ route('physicians.submit-contact-us') }}" method="post" autocomplete="off">
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@csrf
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@if(session('success'))
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@@ -45,8 +34,8 @@
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<div class="row">
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<div class="col-lg-4 form-group mb-4">
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- <label for="">Prefix <span class="text-danger">*</span> </label>
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- <select class="form-control rounded-0 py-3" required name="name_prefix">
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+ <label for="">Prefix</label>
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+ <select class="form-control rounded-0 py-3" name="name_prefix">
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<option value="">Select Prefix</option>
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<option value="Dr.">Dr.</option>
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<option value="Mr.">Mr.</option>
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@@ -60,14 +49,14 @@
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@enderror
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</div>
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<div class="col-lg-4 form-group mb-4">
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- <label for="">First Name <span class="text-danger">*</span> </label>
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+ <label for="">First Name <span>*</span> </label>
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<input type="text" class="form-control rounded-0 py-3" required name="name_first" value="{{ old('name_first') }}">
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@error('name_first')
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<small class="text-warning">{{$message}}</small>
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@enderror
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</div>
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<div class="col-lg-4 form-group mb-4">
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- <label for="">Last Name <span class="text-danger">*</span> </label>
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+ <label for="">Last Name <span>*</span> </label>
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<input type="text" class="form-control rounded-0 py-3" required name="name_last" value="{{ old('name_last') }}">
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@error('name_last')
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<small class="text-warning">{{$message}}</small>
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@@ -75,14 +64,14 @@
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</div>
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</div>
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<div class="form-group mb-4">
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- <label>Practice Name <span class="text-danger">*</span> </label>
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+ <label>Practice Name <span>*</span> </label>
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<input type="text" class="form-control rounded-0 py-3" required name="practice_name" value="{{ old('practice_name') }}">
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@error('practice_name')
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<small class="text-warning">{{$message}}</small>
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@enderror
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</div>
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<div class="form-group mb-4">
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- <label>Email <span class="text-danger">*</span> </label>
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+ <label>Email <span>*</span> </label>
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<input type="email" class="form-control rounded-0 py-3" required name="email" value="{{ old('email') }}">
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@error('email')
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<small class="text-warning">{{$message}}</small>
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@@ -90,14 +79,14 @@
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</div>
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<div class="row">
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<div class="col-lg-6 form-group mb-4">
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- <label>Phone <span class="text-danger">*</span> </label>
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+ <label>Phone <span>*</span> </label>
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<input type="tel" class="form-control rounded-0 py-3 phone" required name="phone" value="{{ old('phone') }}">
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@error('phone')
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<small class="text-warning">{{$message}}</small>
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@enderror
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</div>
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<div class="col-lg-6 form-group mb-4">
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- <label>Zip / Postal Code <span class="text-danger">*</span> </label>
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+ <label>Zip / Postal Code <span>*</span> </label>
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<input type="text" class="form-control rounded-0 py-3 zip" required phone name="zip" value="{{ old('zip') }}">
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@error('zip')
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<small class="text-warning">{{$message}}</small>
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@@ -105,7 +94,7 @@
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</div>
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</div>
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<div class="form-group mb-4">
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- <label>How Can We Help You?<span class="text-danger">*</span></label>
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+ <label>How Can We Help You?<span>*</span></label>
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<textarea name="message" class="form-control rounded-0" required rows="6">{{ old('message') }}</textarea>
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@error('message')
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<small class="text-warning">{{$message}}</small>
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@@ -122,5 +111,4 @@
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</div>
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</div>
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</div>
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-</div>
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@endsection
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