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@@ -30,12 +30,25 @@
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<div class="row justify-content-center">
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<div class="row justify-content-center">
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<div class="col-lg-8">
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<div class="col-lg-8">
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<h5 class="header">Contact Us</h5>
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<h5 class="header">Contact Us</h5>
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- <form class="" action="" method="post">
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+ <form class="" action="{{ route('physicians.submit-contact-us') }}" method="post">
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@csrf
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@csrf
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+
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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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+
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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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+
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<label for="">Full Name <span class="text-danger">*</span> </label>
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<label for="">Full Name <span class="text-danger">*</span> </label>
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<div class="row">
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<div class="row">
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<div class="col-lg-4 form-group mb-4">
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<div class="col-lg-4 form-group mb-4">
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- <select class="form-control rounded-0 py-3" required name="prefix">
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+ <select class="form-control rounded-0 py-3" required name="name_prefix">
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<option value="">Select Prefix</option>
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<option value="">Select Prefix</option>
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<option value="Dr.">Dr.</option>
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<option value="Dr.">Dr.</option>
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<option value="Mr.">Mr.</option>
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<option value="Mr.">Mr.</option>
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@@ -44,7 +57,7 @@
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<option value="Ms.">Ms.</option>
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<option value="Ms.">Ms.</option>
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<option value="Prof.">Prof.</option>
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<option value="Prof.">Prof.</option>
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</select>
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</select>
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- @error('prefix')
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+ @error('name_prefix')
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<small class="text-warning">{{$message}}</small>
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<small class="text-warning">{{$message}}</small>
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@enderror
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@enderror
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</div>
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</div>
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@@ -64,22 +77,37 @@
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<div class="form-group mb-4">
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<div class="form-group mb-4">
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<label>Practice Name <span class="text-danger">*</span> </label>
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<label>Practice Name <span class="text-danger">*</span> </label>
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<input type="text" class="form-control rounded-0 py-3" required name="practice_name" value="{{ old('practice_name') }}">
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<input type="text" class="form-control rounded-0 py-3" required name="practice_name" value="{{ old('practice_name') }}">
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+ @error('practice_name')
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+ <small class="text-warning">{{$message}}</small>
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+ @enderror
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</div>
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</div>
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<div class="form-group mb-4">
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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 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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<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">{{$message}}</small>
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+ @enderror
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</div>
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</div>
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<div class="form-group mb-4">
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<div class="form-group mb-4">
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<label>Phone <span class="text-danger">*</span> </label>
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<label>Phone <span class="text-danger">*</span> </label>
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<input type="tel" class="form-control rounded-0 py-3" required phone name="phone" value="{{ old('phone') }}">
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<input type="tel" class="form-control rounded-0 py-3" required phone name="phone" value="{{ old('phone') }}">
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+ @error('phone')
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+ <small class="text-warning">{{$message}}</small>
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+ @enderror
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</div>
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</div>
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<div class="form-group mb-4">
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<div class="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 class="text-danger">*</span> </label>
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<input type="text" class="form-control rounded-0 py-3" required phone name="zip" value="{{ old('zip') }}">
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<input type="text" class="form-control rounded-0 py-3" required phone name="zip" value="{{ old('zip') }}">
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+ @error('zip')
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+ <small class="text-warning">{{$message}}</small>
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+ @enderror
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</div>
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</div>
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<div class="form-group mb-4">
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<div class="form-group mb-4">
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<label>How Can We Help You?<span class="text-danger">*</span></label>
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<label>How Can We Help You?<span class="text-danger">*</span></label>
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<textarea name="message" class="form-control rounded-0" required rows="6">{{ old('message') }}</textarea>
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<textarea name="message" class="form-control rounded-0" required rows="6">{{ old('message') }}</textarea>
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+ @error('message')
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+ <small class="text-warning">{{$message}}</small>
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+ @enderror
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</div>
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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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<button type="submit" class="btn btn-pry w-100 py-3">SUBMIT</button>
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</form>
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</form>
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