updated sample form

app/Http/Controllers/PhysiciansController.php

@@ -166,7 +166,6 @@ class PhysiciansController extends Controller
 
     public function submitOrderLigators(Request $request){
       $request->validate([
-        'order_date' => 'required|string',
         'company_name' => 'required|string',
         'order_phyisician_name' => 'required|string',
         'phone_number' => 'required|string',

public/css/style.css

@@ -43,6 +43,9 @@ a {
 p {
   font-size: 17px;
 }
+.pointer {
+  cursor: pointer;
+}
 .text-pry {
   color: var(--pry-color);
 }

resources/views/app/physicians/order-products/forms/place-order.blade.php

@@ -11,30 +11,14 @@
 
                 @if(session('success'))
               <div class="alert alert-success fade show" role="alert">
-                <p class="mb-1">Thank you. We have received your order.</p>
+                <p class="mb-1">Thank you. We have received your request.</p>
 
-                <p class="mb-1">Your order # is: {{ session('orderIID') }}</p>
-
-                <p class="mb-1">We will be sending you an email shortly with secure payment options.</p>
+                <p class="mb-1">Your request # is: {{ session('orderIID') }}</p>
               </div>
               @endif
 
 
             </div>
-            <div class="col-lg-6 form-group mb-4">
-                <label>Order Date: <span class="text-danger">*</span> </label>
-                <input type="text" name="order_date" class="form-control bg-white rounded-0 py-3" readonly value="{{date('m/d/Y')}}">
-                @error('order_date')
-                  <small class="text-warning">{{$message}}</small>
-                @enderror
-            </div>
-            <div class="col-lg-6 form-group mb-4">
-                <label>PO # (Optional):</label>
-                <input type="text" class="form-control rounded-0 py-3" name="postal_code" value="{{ old('postal_code') }}">
-                @error('postal_code')
-                  <small class="text-warning">{{$message}}</small>
-                @enderror
-            </div>
         </div>
         <div class="row">
             <div class="col-lg-6 form-group mb-4">
@@ -137,9 +121,6 @@
                     <tr>
                         <th>Ref No</th>
                         <th>Item</th>
-                        <th>Quantity</th>
-                        <th>Price / Unit</th>
-                        <th>Total Amount</th>
                     </tr>
                 </thead>
                 <tbody>
@@ -147,26 +128,11 @@
                         <td class="p-3 v-center">DS905727</td>
                         <td class="p-3 v-center">
                             <div class="">
-                                <div class="mb-4">
-                                    <img src="{{asset('img/snyder.png')}}" class="w-100" alt="">
-                                </div>
                                 <p>Snyder HemBand<sup>TM</sup> disposable hemorrhoidal ligator with integrated obturator.</p>
                                 <p>1 individual package.</p>
                                 <p>Includes 3 latex bands. Latex-free bands available upon request.</p>
                             </div>
                         </td>
-                        <td class="p-3 v-center">
-                            <input type="number" name="quantity" min="1" required v-model="quantity" class="form-control rounded-0 text-center" value="">
-                            @error('quantity')
-                                <small class="text-warning">{{$message}}</small>
-                            @enderror
-                        </td>
-                        <td class="p-3 v-center">$70.00 per unit</td>
-                        <td class="p-3 v-center">
-                            <div class="d-flex align-items-baseline">
-                                <span>$</span> <input type="text" name="total" disabled class="form-control border-0 bg-transparent text-center rounded-0 border-bottom border-dark" :value="quantity * 70 || ''">
-                            </div>
-                        </td>
                     </tr>
                     <tr v-if="quantity">
                         <td colspan="5">
@@ -178,34 +144,11 @@
                     </tr>
                 </tbody>
             </table>
-            <small><em>Prices are inclusive of all taxes. Prices valid in the U.S. only.</em></small>
-        </div>
-        <div class="form-group mb-4">
-            <p class="mb-2">Delivery Options</p>
-            <div class="form-check">
-                <label class="ms-2 mb-2 pointer">
-                    <input type="radio" required class="form-check-input" name="delivery_option" value="FedEx Standard Overnight (Next business day by 3PM) - FREE OF CHARGE">
-                    <span>FedEx Standard Overnight (Next business day by 3PM) - FREE OF CHARGE</span>
-                </label>
-                <label class="ms-2 mb-2 pointer">
-                    <input type="radio" required class="form-check-input" name="delivery_option" value="FedEx Priority Overnight (Next business day by 10AM) - $40.00">
-                    <span>FedEx Priority Overnight (Next business day by 10AM) - $40.00</span>
-                </label>
-                <label class="ms-2 mb-2 pointer">
-                    <input type="radio" required class="form-check-input" name="delivery_option" value="FedEx First Overnight (Next business day by 8AM) - $150.00">
-                    <span>FedEx First Overnight (Next business day by 8AM) - $150.00</span>
-                </label>
-            </div>
-            <small><em>* Priority and First Overnight shipping rates apply to a box of 20 units. Shipping rates may vary, subject to order quantity. FedEx does not deliver to PO Box/APO addresses. Some FedEx services are not available in all areas. Please note that all orders placed after 1pm EST will be processed next business day. No Saturday or Sunday delivery.</em> </small>
-        </div>
-        <div class="form-group mb-4">
-            <p class="mb-2">Payment Method</p>
-            <p><b>After you submit this form, you will receive an invoice with secure payment options.</b></p>
         </div>
         <div class="form-check mb-4">
-            <input class="form-check-input" type="checkbox" name="agrees_to_terms" required />
             <label class="form-check-label pointer">
-                By submitting this order, buyer has read, understands, and agrees to MDE Medical's <a target="_blank" href="{{route('terms')}}">Terms and Conditions</a>. Any overdue payments shall bear interest at a rate equal to the lesser of: (i) 1.5% per month, or (ii) the maximum amount permitted by law, assessed from the date payment was initially due.
+              <input class="form-check-input" type="checkbox" name="agrees_to_terms" required />
+                By submitting this request, I confirm that I am a physician or otherwise duly licensed healthcare practitioner authorized to provide hemorrhoid ligation treatment services in the United States.
             </label>
         </div>
         <div class="form-group mb-4">

resources/views/app/physicians/order-products/ligators.blade.php

@@ -1,7 +1,7 @@
 @extends('layouts.physicians')
 @section('content')
 
-<div class="bg-light">
+<div class="bg-light d-lg-block d-none">
   <div class="container pt-3">
     <nav class="mb-0">
       <ol class="breadcrumb">
@@ -18,7 +18,7 @@
   <div class="container">
     <div class="row justify-content-center">
       <div class="col-lg-7 text-center">
-        <h5 class="title m-0">Ligators</h5>
+        <h5 class="title m-0">Request Samples</h5>
       </div>
     </div>
   </div>
@@ -30,9 +30,15 @@
       @include('app.physicians.order-products.sidenav')
     </div>
     <div class="col-lg-8">
-      <h4 class="header">Order Snyder HemBand Ligators Today</h4>
-      <p class="mt-3 mb-4">If you are a licensed healthcare practitioner in the United States, you’re eligible to order the Snyder HemBand using this online form. You may also use <u><a href="https://23496735.fs1.hubspotusercontent-na1.net/hubfs/23496735/HemBand%20with%20Integrated%20Obturator%20-%20Order%20Form.pdf" target="_blank">this PDF-based form</a></u> to order via fax or email.</p>
-
+      <div class="d-flex flex-column">
+        <div class="order-lg-1 order-2">
+          <h4 class="header">Order Snyder HemBand Samples Today!</h4>
+          <p class="mt-3 mb-4">If you are a licensed healthcare practitioner in the United States, you’re eligible to request Snyder HemBand samples using this online form. You may also email us at <u><a href="mailto:support@hemband.com">support@hemband.com</a></u> for assistance.</p>
+        </div>
+        <div class="mb-4 order-lg-2 order-1">
+            <img src="{{asset('img/snyder.png')}}" class="w-100" alt="">
+        </div>
+      </div>
      @include('app.physicians.order-products.forms.place-order')
 
       <p>However, if you or your practice have not received training on the Snyder HemBand System, you can request training online and we will contact you shortly to schedule.</p>

routes/web.php

@@ -38,7 +38,8 @@ Route::prefix('/physicians/')->name('physicians.')->group(function () {
     Route::get('/practice-support/directory-listing', [PhysiciansController::class, 'practiceSupportDirectoryListing'])->name('practice-support-directory');
     Route::post('/practice-support/submit-directory-listing', [PhysiciansController::class, 'submitPracticeSupportDirectoryListing'])->name('submit-practice-support-directory-listing-request');
     Route::get('/order-products', [PhysiciansController::class, 'orderProducts'])->name('order-products');
-    Route::get('/order-products/ligators', [PhysiciansController::class, 'orderProductsLigators'])->name('order-products-ligators');
+    // Route::get('/order-products/ligators', [PhysiciansController::class, 'orderProductsLigators'])->name('order-products-ligators');
+    Route::get('/request-samples', [PhysiciansController::class, 'orderProductsLigators'])->name('order-products-ligators');
     Route::post('/submit-order-ligators', [PhysiciansController::class, 'submitOrderLigators'])->name('submit-order-ligators');
     Route::get('/order-products/marketing-materials', [PhysiciansController::class, 'orderProductsMarketing'])->name('order-products-marketing');
     Route::post('/order-products/submit-marketing-materials-request', [PhysiciansController::class, 'submitOrderProductsMarketing'])->name('submit-order-products-marketing');