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@@ -34,49 +34,88 @@
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<p class="mt-4">We know that marketing materials are a huge asset in helping patients and staff understand the Snyder HemBand procedure. Because of this, we’re happy to provide a variety of marketing materials at no cost to you or your practice.</p>
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<p>To place an order, please fill out the form below or submit an order form via fax or email <a href="mailto:info@snyderhemband.org">info@snyderhemband.org</a>.</p>
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<div class="bg-light p-4">
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- <form class="" action="" method="post">
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+ <form class="" action="{{ route('physicians.submit-order-products-marketing') }}" method="post">
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@csrf
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<div class="row">
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+ <div class="col-12">
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+ @if($errors->any())
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+ <div class="alert alert-danger fade show" role="alert">
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+ There were errors found!
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+ </div>
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+ @endif
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+ @if(session('success'))
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+ <div class="alert alert-success fade show" role="alert">
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+ {{session('success')}}
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+ </div>
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+ @endif
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+ </div>
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<div class="col-lg-6 form-group mb-4">
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<label>First Name <span class="text-danger">*</span> </label>
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<input type="text" class="form-control rounded-0 py-3" required name="name_first" value="{{ old('name_first') }}">
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+ @error('name_first')
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+ <small class="text-warning">{{$message}}</small>
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+ @enderror
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</div>
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<div class="col-lg-6 form-group mb-4">
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<label>Last Name <span class="text-danger">*</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">{{$message}}</small>
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+ @enderror
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</div>
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</div>
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<div class="form-group mb-4">
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<label>Title <span class="text-danger">*</span> </label>
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<input type="text" class="form-control rounded-0 py-3" required name="title" value="{{ old('title') }}">
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+ @error('title')
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+ <small class="text-warning">{{$message}}</small>
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+ @enderror
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</div>
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<div class="row">
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<div class="col-lg-4 form-group mb-4">
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<label>Practice Name <span class="text-danger">*</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">{{$message}}</small>
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+ @enderror
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</div>
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<div class="col-lg-5 form-group mb-4">
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<label>Practice Address <span class="text-danger">*</span> </label>
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<input type="text" class="form-control rounded-0 py-3" required name="practice_address" value="{{ old('practice_address') }}">
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+ @error('practice_address')
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+ <small class="text-warning">{{$message}}</small>
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+ @enderror
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</div>
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<div class="col-lg-3 form-group mb-4">
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<label>Practice Zip Code <span class="text-danger">*</span> </label>
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- <input type="text" class="form-control rounded-0 py-3" required name="practice_zip" value="{{ old('practice_zip') }}">
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+ <input type="text" class="form-control rounded-0 py-3" required name="zip" value="{{ old('zip') }}">
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+ @error('zip')
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+ <small class="text-warning">{{$message}}</small>
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+ @enderror
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</div>
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</div>
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<div class="row">
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<div class="col-lg-6 form-group mb-4">
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<label>Contact Phone Number <span class="text-danger">*</span> </label>
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- <input type="tel" class="form-control rounded-0 py-3 phone" required placeholder="(xxx) xxx-xxxx" name="contact_phone" value="{{ old('contact_phone') }}">
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+ <input type="tel" class="form-control rounded-0 py-3 phone" required placeholder="(xxx) xxx-xxxx" name="phone" value="{{ old('phone') }}">
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+ @error('phone')
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+ <small class="text-warning">{{$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>Contact Email <span class="text-danger">*</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">{{$message}}</small>
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+ @enderror
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</div>
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</div>
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<div class="form-group mb-4">
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<label>Order request</label>
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- <textarea name="request" class="form-control rounded-0" rows="6">{{ old('request') }}</textarea>
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+ <textarea name="comment" class="form-control rounded-0" rows="6">{{ old('comment') }}</textarea>
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+ @error('comment')
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+ <small class="text-warning">{{$message}}</small>
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+ @enderror
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</div>
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<button type="submit" class="btn btn-pry w-100 py-3">SUBMIT</button>
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</form>
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