Samson Mutunga преди 2 години
родител
ревизия
f13650d411
променени са 2 файла, в които са добавени 578 реда и са изтрити 279 реда
  1. 343 0
      resources/views/app/gi-survey-questions-depricated.blade.php
  2. 235 279
      resources/views/app/gi-survey-questions.blade.php

+ 343 - 0
resources/views/app/gi-survey-questions-depricated.blade.php

@@ -0,0 +1,343 @@
+@extends('layouts.app')
+@section('content')
+<link rel="stylesheet" href="{{ asset('css/nouislider.min.css') }}" />
+<script src="{{ asset('js/nouislider.min.js') }}"></script>
+
+<style>
+    .form-group label {
+        font-weight: 500;
+    }
+
+    .form-group label span {
+        font-weight: 400;
+    }
+
+    .noUiSlider {
+        margin: 58px 0;
+        padding: 0 15px;
+    }
+</style>
+<div class="bg-light">
+    <div class="container pt-3">
+        <nav class="mb-0">
+            <ol class="breadcrumb">
+                <li class="breadcrumb-item"><a href="{{route('index')}}"><u>Home</u></a></li>
+                <li class="breadcrumb-item active" aria-current="page">Survey Questions</li>
+            </ol>
+        </nav>
+    </div>
+</div>
+<div class="bg-grey py-5">
+    <div class="container">
+        <div class="row justify-content-center">
+            <div class="col-lg-7 text-center">
+                <h5 class="subtitle">Survey Questions</h5>
+            </div>
+        </div>
+    </div>
+</div>
+<div class="container py-4">
+  <div class="row justify-content-center">
+    <div class="col-lg-8">
+      <div class="container shadow p-4">
+          <div class="row justify-content-center">
+              @if(session('success'))
+              <div class="col-12">
+                  <div class="alert alert-success" role="alert">
+                      <h4 class="alert-heading">Congratulations!!</h4>
+                      <p>You have successfully completed this survey. Eligible submissions will receive a digital gift cards in 7 business days to the email provided in the survey. </p>
+                  </div>
+              </div>
+              @else
+              <div id="surveyQuestionsComponent" class="col-md-12">
+                  <form action="{{ route('submit-gi-survey-questions') }}" method="POST">
+                      @csrf
+                      <div class="row mb-3">
+                          <div class="col-12">
+                              <div class="">
+                                  <div class="row">
+                                      <div class="col-md-12 mb-3">
+                                          <div class="form-group">
+                                              <label>Name<sup class="text-danger">*</sup></label>
+                                              <input type="text" class="form-control" name="name" value="{{ old('name') }}" required />
+                                          </div>
+                                      </div>
+                                      <div class="col-md-6 mb-3">
+                                          <div class="form-group">
+                                              <label>Email<sup class="text-danger">*</sup></label>
+                                              <input type="email" class="form-control" name="email" value="{{ old('email') }}" required />
+                                              <small class="text-muted">(to receive digital gift card)</small>
+                                          </div>
+                                      </div>
+                                      <div class="col-md-6 mb-3">
+                                          <div class="form-group">
+                                              <label>Mobile Number</label>
+                                              <input type="text" class="form-control phone" name="mobile_number" value="{{ old('mobile_number') }}" />
+                                          </div>
+                                      </div>
+                                  </div>
+                                  <div class="row">
+                                      <div class="col-md-6 mb-3">
+                                          <div class="form-group ">
+                                              <label>Practice Address</label>
+                                              <input type="text" class="form-control" name="practice_address_line_1" value="{{ old('practice_address_line_1') }}" />
+                                          </div>
+                                      </div>
+                                      <div class="col-md-6 mb-3">
+                                          <div class="form-group ">
+                                              <label>Practice Address Street</label>
+                                              <input type="text" class="form-control" name="practice_address_line_2" value="{{ old('practice_address_line_2') }}" />
+                                          </div>
+                                      </div>
+                                      <div class="col-md-4 mb-3">
+                                          <div class="form-group ">
+                                              <label>Practice Address City</label>
+                                              <input type="text" class="form-control" name="practice_address_city" value="{{ old('practice_address_city') }}" />
+                                          </div>
+                                      </div>
+                                      <div class="col-md-4 mb-3">
+                                          <div class="form-group">
+                                              <label>Practice Address State</label>
+                                              <select class="form-control" name="practice_address_state">
+                                                  <option value=""></option>
+                                                  @foreach(config('constants.us_states') as $stateKey => $stateLabel)
+                                                  <option value="{{ $stateKey }}" <?= old('practice_address_state') === $stateKey ? 'selected':'' ?>>{{ $stateKey }}</option>
+                                                  @endforeach
+                                              </select>
+                                          </div>
+                                      </div>
+                                      <div class="col-md-4 mb-3">
+                                          <div class="form-group ">
+                                              <label>Practice Address Zip Code</label>
+                                              <input type="text" class="form-control zip" name="practice_address_zip_code" value="{{ old('practice_address_zip_code') }}" />
+                                          </div>
+                                      </div>
+                                  </div>
+                              </div>
+                          </div>
+                      </div>
+                      <div class="row mb-3">
+                          <div class="col-12 question">
+                              <div class="form-group">
+                                  <label>Are you a gastroenterologist?</label>
+                                  <div class="d-flex">
+                                      <label class="me-3"><input type="radio" name="are_you_a_gastroenterologist" v-model="form.are_you_a_gastroenterologist" value="YES" /> <span>Yes</span></label>
+                                      <label><input type="radio" name="are_you_a_gastroenterologist" v-model="form.are_you_a_gastroenterologist" value="NO" /> <span>No</span></label>
+                                  </div>
+                              </div>
+                              <div v-if="form.are_you_a_gastroenterologist == 'NO'" class="form-group">
+                                  <label>Your speciality?<sup class="text-danger">*</sup></label>
+                                  <input type="text" class="form-control" name="your_specialty" value="{{ old('your_specialty') }}" required />
+                              </div>
+
+                          </div>
+                      </div>
+                      <div class="row mb-3">
+                          <div class="col-12 question">
+                              <div class="form-group">
+                                  <label>Years in the practice</label>
+                                  <div id="rangeSlider" class="noUiSlider"></div>
+                                  <input type="hidden" name="years_in_practice" :value="form.years_in_practice" />
+                              </div>
+
+                          </div>
+                      </div>
+                      <div class="row mb-3">
+                          <div class="col-12 question">
+                              <div class="form-group">
+                                  <label>Where do you perform your regular procedures?</label>
+                                  <div class="d-flex flex-column">
+                                      <label><input type="checkbox" name="where_do_you_perform_regular_procedures[]" value="Office"> <span>Office</span></label>
+                                      <label><input type="checkbox" name="where_do_you_perform_regular_procedures[]" value="Endoscopy Center"> <span>Endoscopy Center</span></label>
+                                      <label><input type="checkbox" name="where_do_you_perform_regular_procedures[]" value="ASC"> <span>ASC</span></label>
+                                      <label><input type="checkbox" name="where_do_you_perform_regular_procedures[]" value="Hospital"> <span>Hospital</span></label>
+                                  </div>
+                              </div>
+
+                          </div>
+                      </div>
+                      <div class="row mb-3">
+                          <div class="col-12 question">
+                              <div class="form-group">
+                                  <label>Do you perform any procedures for the Hemorrhoids?</label>
+                                  <div class="d-flex">
+                                      <label class="me-3"><input type="radio" name="do_you_perform_any_procedures_for_the_hemorrhoids" v-model="form.do_you_perform_any_procedures_for_the_hemorrhoids" value="YES" /> <span>Yes</span></label>
+                                      <label><input type="radio" name="do_you_perform_any_procedures_for_the_hemorrhoids" v-model="form.do_you_perform_any_procedures_for_the_hemorrhoids" value="NO" /> <span>No, I refer to the speciality centers</span></label>
+                                  </div>
+                              </div>
+                              <div v-if="form.do_you_perform_any_procedures_for_the_hemorrhoids == 'YES'" class="form-group">
+                                  <label>If yes, what types of the procedures you preform?<sup class="text-danger">*</sup></label>
+                                  <div class="d-flex flex-column">
+                                      <label><input type="checkbox" name="what_types_of_the_procedures_you_preform[]" value="Hemorrhoid Banding" /> <span>Hemorrhoid Banding</span></label>
+                                      <label><input type="checkbox" name="what_types_of_the_procedures_you_preform[]" value="Infrared Coagulation" /> <span>Infrared Coagulation</span></label>
+                                      <label><input type="checkbox" name="what_types_of_the_procedures_you_preform[]" value="Sclerotherapy" /> <span>Sclerotherapy</span></label>
+                                      <label><input type="checkbox" name="what_types_of_the_procedures_you_preform[]" value="Hemorrhoid stapling" /> <span>Hemorrhoid stapling</span></label>
+                                      <label><input type="checkbox" name="what_types_of_the_procedures_you_preform[]" value="Hemorrhoidectomy" /> <span>Hemorrhoidectomy</span></label>
+                                  </div>
+                              </div>
+
+                          </div>
+                      </div>
+                      <div class="row mb-3">
+                          <div class="col-12 question">
+                              <div class="form-group">
+                                  <label>Have you ever tried or used banding technics using Rubber band ligation?</label>
+                                  <div class="d-flex">
+                                      <label class="me-3"><input type="radio" name="used_banding_technics_using_rubber_band_ligation" v-model="form.used_banding_technics_using_rubber_band_ligation" value="YES" /> <span>Yes</span></label>
+                                      <label class="me-3"><input type="radio" name="used_banding_technics_using_rubber_band_ligation" v-model="form.used_banding_technics_using_rubber_band_ligation" value="NO" /> <span>No</span></label>
+                                  </div>
+                              </div>
+                              <div v-if="form.used_banding_technics_using_rubber_band_ligation == 'YES'" class="form-group">
+                                  <label>If yes, what is your experience with RBL treatment for hemorrhoids?<sup class="text-danger">*</sup></label>
+                                  <textarea class="form-control" name="experience_with_rbl_treatment_for_hemorrhoids"></textarea>
+                              </div>
+                              <div v-if="form.used_banding_technics_using_rubber_band_ligation == 'NO'" class="form-group">
+                                  <label>If No, Would you like to learn more about hemorroidal treatment option using rubber band ligation?<sup class="text-danger">*</sup></label>
+                                  <div class="d-flex">
+                                      <label class="me-3"><input type="radio" name="interested_to_learn_more_about_hemorroidal_treatment_option_using_rubber_band_ligation" value="YES" /> <span>Yes</span></label>
+                                      <label class="me-3"><input type="radio" name="interested_to_learn_more_about_hemorroidal_treatment_option_using_rubber_band_ligation" value="NO" /> <span>No</span></label>
+                                      <label><input type="radio" name="interested_to_learn_more_about_hemorroidal_treatment_option_using_rubber_band_ligation" value="NOT SURE" /> <span>Not sure</span></label>
+                                  </div>
+                              </div>
+
+                          </div>
+                      </div>
+
+                      <div class="row mb-3">
+                          <div class="col-12 question">
+                              <div class="form-group">
+                                  <label>Would you like to recive free samples of the Snyder HemBand?</label>
+                                  <div class="d-flex">
+                                      <label class="me-3"><input type="radio" name="recive_free_samples_of_the_snyder_hem_band" value="YES" /> <span>Yes</span></label>
+                                      <label class="me-3"><input type="radio" name="recive_free_samples_of_the_snyder_hem_band" value="NO" /> <span>No</span></label>
+                                  </div>
+                              </div>
+                          </div>
+                      </div>
+
+                      <div class="row mb-3">
+                          <div class="col-12 question">
+                              <div class="form-group">
+                                  <label>What would be the best way to contact you?</label>
+                                  <div class="d-flex">
+                                      <label class="me-3"><input type="radio" name="best_way_to_contact_you" value="Phone Call" /> <span>Phone call</span></label>
+                                      <label class="me-3"><input type="radio" name="best_way_to_contact_you" value="Email" /> <span>Email</span></label>
+                                      <label><input type="radio" name="best_way_to_contact_you" value="Text" /> <span>Text</span></label>
+                                  </div>
+                              </div>
+                          </div>
+                      </div>
+
+                      <div class="row mb-3">
+                          <div class="col-12 question">
+                              <div class="form-group">
+                                  <label>Preferred time to call:</label>
+                                  <div class="d-flex flex-wrap mb-3">
+                                      <label class="me-3 text-muted">Day(s):</label>
+                                      <label class="me-3"><input type="checkbox" name="preferred_day_to_call[]" value="Monday" /> <span>M</span></label>
+                                      <label class="me-3"><input type="checkbox" name="preferred_day_to_call[]" value="Tuesday" /> <span>Tu</span></label>
+                                      <label class="me-3"><input type="checkbox" name="preferred_day_to_call[]" value="Wednesday" /> <span>W</span></label>
+                                      <label class="me-3"><input type="checkbox" name="preferred_day_to_call[]" value="Thursday" /> <span>Th</span></label>
+                                      <label class="me-3"><input type="checkbox" name="preferred_day_to_call[]" value="Friday" /> <span>F</span></label>
+                                      <label class="me-3"><input type="checkbox" name="preferred_day_to_call[]" value="Saturday" /> <span>Sa</span></label>
+                                      <label class="me-3"><input type="checkbox" name="preferred_day_to_call[]" value="Sunday" /> <span>Su</span></label>
+                                  </div>
+                                  <div class="d-flex flex-wrap mb-3">
+                                      <label class="me-3 text-muted">Time(s) <small>(your local time)</small>:</label>
+                                      <label class="me-3"><input type="checkbox" name="preferred_time_to_call[]" value="8-10" /> <span>8-10</span></label>
+                                      <label class="me-3"><input type="checkbox" name="preferred_time_to_call[]" value="10-12" /> <span>10-12</span></label>
+                                      <label class="me-3"><input type="checkbox" name="preferred_time_to_call[]" value="12-2" /> <span>12-2</span></label>
+                                      <label class="me-3"><input type="checkbox" name="preferred_time_to_call[]" value="2-4" /> <span>2-4</span></label>
+                                      <label class="me-3"><input type="checkbox" name="preferred_time_to_call[]" value="4-6" /> <span>4-6</span></label>
+                                  </div>
+                              </div>
+                          </div>
+                      </div>
+
+                      <div class="row mb-3">
+                          <div class="col-12 question">
+                              <div class="form-group">
+                                  <label>Your comments</label>
+                                  <textarea name="your_comments" class="form-control"></textarea>
+                              </div>
+                          </div>
+                      </div>
+
+                      <div class="row mt-3">
+                          <div class="col-md-12">
+                              <div class="form-group mb-4">
+                                  {!! htmlFormSnippet() !!}
+                                  @error('g-recaptcha-response')
+                                  <small class="text-danger"><i class="fas fa-exclamation-triangle mr-2"></i>Invalid</small>
+                                  @enderror
+                              </div>
+                          </div>
+                          <div class="col-12">
+                              <button type="submit" class="btn btn-pry w-100 py-3">SUBMIT</button>
+                          </div>
+                      </div>
+                  </form>
+              </div>
+              @endif
+          </div>
+      </div>
+    </div>
+  </div>
+</div>
+
+<script>
+    var surveyQuestionsComponent = new Vue({
+        el: '#surveyQuestionsComponent',
+        data: {
+            form: {
+                are_you_a_gastroenterologist: "{{ old('are_you_a_gastroenterologist') }}",
+                years_in_practice: "{{ old('years_in_practice') }}"
+            }
+        },
+        methods: {
+            initRangeSlider: function() {
+                var self = this;
+                var slider = document.getElementById('rangeSlider');
+                var format = {
+                    to: function(value) {
+                        return Math.round(value);
+                    },
+                    from: function(value) {
+                        return Math.round(value);
+                    }
+                };
+
+                noUiSlider.create(slider, {
+                    start: 0,
+                    step: 5,
+                    connect: 'lower',
+                    range: {
+                        'min': 0,
+                        'max': 70
+                    },
+                    tooltips: true,
+                    format: format,
+                    pips: {
+                        mode: 'steps',
+                        format: format,
+                    },
+                });
+                slider.noUiSlider.on('update', function(values, handle) {
+                    self.form.years_in_practice = values[0];
+                });
+
+                @if(old('years_in_practice'))
+                    slider.noUiSlider.set(parseInt("{{old('years_in_practice')}}"));
+                @endif
+            },
+            init: function() {
+                this.initRangeSlider();
+            }
+        },
+        mounted: function() {
+            this.init();
+        }
+    });
+</script>
+
+@endsection

+ 235 - 279
resources/views/app/gi-survey-questions.blade.php

@@ -16,13 +16,65 @@
         margin: 58px 0;
         padding: 0 15px;
     }
+
+    .notify.alert-warning {
+        background-color: #f9f6ee;
+        border-color: #ffecb5;
+    }
+
+    .notify i {
+        font-size: 40px;
+    }
+
+    .checkbox label:after {
+        content: '';
+        display: table;
+        clear: both;
+    }
+
+    .checkbox .cr {
+        position: relative;
+        display: inline-block;
+        border: 1px solid #a9a9a9;
+        border-radius: .25em;
+        width: 1.3em;
+        height: 1.3em;
+        float: left;
+        margin-right: .5em;
+    }
+
+    .checkbox .cr .cr-icon {
+        position: absolute;
+        font-size: .8em;
+        line-height: 0;
+        top: 50%;
+        left: 15%;
+    }
+
+    .checkbox label input[type="checkbox"] {
+        display: none;
+    }
+
+    .checkbox label input[type="checkbox"]+.cr>.cr-icon {
+        opacity: 0;
+        font-weight: bold;
+    }
+
+    .checkbox label input[type="checkbox"]:checked+.cr>.cr-icon {
+        opacity: 1;
+        color: var(--pry-color);
+    }
+
+    .checkbox label input[type="checkbox"]:disabled+.cr {
+        opacity: .5;
+    }
 </style>
 <div class="bg-light">
     <div class="container pt-3">
         <nav class="mb-0">
             <ol class="breadcrumb">
-                <li class="breadcrumb-item"><a href="{{route('index')}}"><u>Home</u></a></li>
-                <li class="breadcrumb-item active" aria-current="page">Survey Questions</li>
+                <li class="breadcrumb-item"><a href="{{ route('index') }}"><u>Home</u></a></li>
+                <li class="breadcrumb-item active" aria-current="page">Hemorrhoid Treatment Survey</li>
             </ol>
         </nav>
     </div>
@@ -31,258 +83,200 @@
     <div class="container">
         <div class="row justify-content-center">
             <div class="col-lg-7 text-center">
-                <h5 class="subtitle">Survey Questions</h5>
+                <h5 class="subtitle">Hemorrhoid Treatment Survey</h5>
             </div>
         </div>
     </div>
 </div>
 <div class="container py-4">
-  <div class="row justify-content-center">
-    <div class="col-lg-8">
-      <div class="container shadow p-4">
-          <div class="row justify-content-center">
-              @if(session('success'))
-              <div class="col-12">
-                  <div class="alert alert-success" role="alert">
-                      <h4 class="alert-heading">Congratulations!!</h4>
-                      <p>You have successfully completed this survey. Eligible submissions will receive a digital gift cards in 7 business days to the email provided in the survey. </p>
-                  </div>
-              </div>
-              @else
-              <div id="surveyQuestionsComponent" class="col-md-12">
-                  <form action="{{ route('submit-gi-survey-questions') }}" method="POST">
-                      @csrf
-                      <div class="row mb-3">
-                          <div class="col-12">
-                              <div class="">
-                                  <div class="row">
-                                      <div class="col-md-12 mb-3">
-                                          <div class="form-group">
-                                              <label>Name<sup class="text-danger">*</sup></label>
-                                              <input type="text" class="form-control" name="name" value="{{ old('name') }}" required />
-                                          </div>
-                                      </div>
-                                      <div class="col-md-6 mb-3">
-                                          <div class="form-group">
-                                              <label>Email<sup class="text-danger">*</sup></label>
-                                              <input type="email" class="form-control" name="email" value="{{ old('email') }}" required />
-                                              <small class="text-muted">(to receive digital gift card)</small>
-                                          </div>
-                                      </div>
-                                      <div class="col-md-6 mb-3">
-                                          <div class="form-group">
-                                              <label>Mobile Number</label>
-                                              <input type="text" class="form-control phone" name="mobile_number" value="{{ old('mobile_number') }}" />
-                                          </div>
-                                      </div>
-                                  </div>
-                                  <div class="row">
-                                      <div class="col-md-6 mb-3">
-                                          <div class="form-group ">
-                                              <label>Practice Address</label>
-                                              <input type="text" class="form-control" name="practice_address_line_1" value="{{ old('practice_address_line_1') }}" />
-                                          </div>
-                                      </div>
-                                      <div class="col-md-6 mb-3">
-                                          <div class="form-group ">
-                                              <label>Practice Address Street</label>
-                                              <input type="text" class="form-control" name="practice_address_line_2" value="{{ old('practice_address_line_2') }}" />
-                                          </div>
-                                      </div>
-                                      <div class="col-md-4 mb-3">
-                                          <div class="form-group ">
-                                              <label>Practice Address City</label>
-                                              <input type="text" class="form-control" name="practice_address_city" value="{{ old('practice_address_city') }}" />
-                                          </div>
-                                      </div>
-                                      <div class="col-md-4 mb-3">
-                                          <div class="form-group">
-                                              <label>Practice Address State</label>
-                                              <select class="form-control" name="practice_address_state">
-                                                  <option value=""></option>
-                                                  @foreach(config('constants.us_states') as $stateKey => $stateLabel)
-                                                  <option value="{{ $stateKey }}" <?= old('practice_address_state') === $stateKey ? 'selected':'' ?>>{{ $stateKey }}</option>
-                                                  @endforeach
-                                              </select>
-                                          </div>
-                                      </div>
-                                      <div class="col-md-4 mb-3">
-                                          <div class="form-group ">
-                                              <label>Practice Address Zip Code</label>
-                                              <input type="text" class="form-control zip" name="practice_address_zip_code" value="{{ old('practice_address_zip_code') }}" />
-                                          </div>
-                                      </div>
-                                  </div>
-                              </div>
-                          </div>
-                      </div>
-                      <div class="row mb-3">
-                          <div class="col-12 question">
-                              <div class="form-group">
-                                  <label>Are you a gastroenterologist?</label>
-                                  <div class="d-flex">
-                                      <label class="me-3"><input type="radio" name="are_you_a_gastroenterologist" v-model="form.are_you_a_gastroenterologist" value="YES" /> <span>Yes</span></label>
-                                      <label><input type="radio" name="are_you_a_gastroenterologist" v-model="form.are_you_a_gastroenterologist" value="NO" /> <span>No</span></label>
-                                  </div>
-                              </div>
-                              <div v-if="form.are_you_a_gastroenterologist == 'NO'" class="form-group">
-                                  <label>Your speciality?<sup class="text-danger">*</sup></label>
-                                  <input type="text" class="form-control" name="your_specialty" value="{{ old('your_specialty') }}" required />
-                              </div>
+    <div class="row justify-content-center">
+        <div class="col-lg-8">
+            <div class="container shadow p-4">
+                <div class="row">
+                    <div class="col-md-12">
+                        <div class="notify alert alert-warning d-flex flex-column flex-md-row align-items-center" role="alert">
+                            <i class="fa-duotone fa-circle-info fa-fw"></i>
+                            <div class="ms-2 mt-2 mt-md-0">
+                                <div>Are you a <b>gastroenterologist</b> who treats hemorrhoids?</div>
+                                <div>Receive a <b>$50 Amazon Gift Card</b> to Take a 5 Minute Telephone Survey</div>
+                            </div>
+                        </div>
+                    </div>
+                </div>
+                <div class="row justify-content-center">
+                    @if (session('success'))
+                    <div class="col-12">
+                        <div class="alert alert-success" role="alert">
+                            <h4 class="alert-heading">Congratulations!!</h4>
+                            <p>You have successfully completed this survey. Eligible submissions will receive a
+                                digital gift cards in 7 business days to the email provided in the survey. </p>
+                        </div>
+                    </div>
+                    @else
+                    <div id="surveyQuestionsComponent" class="col-md-12">
+                        <form action="{{ route('submit-gi-survey-questions') }}" method="POST">
+                            @csrf
+
+                            <div class="row mb-3">
+                                <div class="col-12 question">
+                                    <div class="form-group">
+                                        <label>Are you a gastroenterologist?</label>
+                                        <div class="d-flex">
+                                            <label class="me-3"><input type="radio" name="are_you_a_gastroenterologist" v-model="form.are_you_a_gastroenterologist" value="YES" />
+                                                <span>Yes</span></label>
+                                            <label><input type="radio" name="are_you_a_gastroenterologist" v-model="form.are_you_a_gastroenterologist" value="NO" />
+                                                <span>No</span></label>
+                                        </div>
+                                    </div>
+                                    <div v-if="form.are_you_a_gastroenterologist == 'NO'" class="form-group">
+                                        <label>Your speciality?<sup class="text-danger">*</sup></label>
+                                        <input type="text" class="form-control" name="your_specialty" value="{{ old('your_specialty') }}" required />
+                                    </div>
+                                </div>
+                            </div>
 
-                          </div>
-                      </div>
-                      <div class="row mb-3">
-                          <div class="col-12 question">
-                              <div class="form-group">
-                                  <label>Years in the practice</label>
-                                  <div id="rangeSlider" class="noUiSlider"></div>
-                                  <input type="hidden" name="years_in_practice" :value="form.years_in_practice" />
-                              </div>
+                            <div class="row mb-3">
+                                <div class="col-12 question">
+                                    <div class="form-group">
+                                        <label>How many patients per week, on average, do you see who have hemorrhoids?</label>
+                                        <input type="number" class="form-control" name="number_of_patients_per_week" value="{{ old('number_of_patients_per_week') }}" />
+                                    </div>
+                                </div>
+                            </div>
 
-                          </div>
-                      </div>
-                      <div class="row mb-3">
-                          <div class="col-12 question">
-                              <div class="form-group">
-                                  <label>Where do you perform your regular procedures?</label>
-                                  <div class="d-flex flex-column">
-                                      <label><input type="checkbox" name="where_do_you_perform_regular_procedures[]" value="Office"> <span>Office</span></label>
-                                      <label><input type="checkbox" name="where_do_you_perform_regular_procedures[]" value="Endoscopy Center"> <span>Endoscopy Center</span></label>
-                                      <label><input type="checkbox" name="where_do_you_perform_regular_procedures[]" value="ASC"> <span>ASC</span></label>
-                                      <label><input type="checkbox" name="where_do_you_perform_regular_procedures[]" value="Hospital"> <span>Hospital</span></label>
-                                  </div>
-                              </div>
+                            <div class="row mb-3">
+                                <div class="col-12 question">
+                                    <div class="form-group">
+                                        <label>Do you currently perform rubber band ligation (RBL) for hemorrhoid treatment?</label>
+                                        <div class="d-flex">
+                                            <label class="me-3"><input type="radio" name="performs_rubber_band_ligation" v-model="form.performs_rubber_band_ligation" value="YES" /> <span>Yes</span></label>
+                                            <label><input type="radio" name="performs_rubber_band_ligation" v-model="form.performs_rubber_band_ligation" value="NO" /> <span>No</span></label>
+                                        </div>
+                                    </div>
+                                </div>
+                            </div>
 
-                          </div>
-                      </div>
-                      <div class="row mb-3">
-                          <div class="col-12 question">
-                              <div class="form-group">
-                                  <label>Do you perform any procedures for the Hemorrhoids?</label>
-                                  <div class="d-flex">
-                                      <label class="me-3"><input type="radio" name="do_you_perform_any_procedures_for_the_hemorrhoids" v-model="form.do_you_perform_any_procedures_for_the_hemorrhoids" value="YES" /> <span>Yes</span></label>
-                                      <label><input type="radio" name="do_you_perform_any_procedures_for_the_hemorrhoids" v-model="form.do_you_perform_any_procedures_for_the_hemorrhoids" value="NO" /> <span>No, I refer to the speciality centers</span></label>
-                                  </div>
-                              </div>
-                              <div v-if="form.do_you_perform_any_procedures_for_the_hemorrhoids == 'YES'" class="form-group">
-                                  <label>If yes, what types of the procedures you preform?<sup class="text-danger">*</sup></label>
-                                  <div class="d-flex flex-column">
-                                      <label><input type="checkbox" name="what_types_of_the_procedures_you_preform[]" value="Hemorrhoid Banding" /> <span>Hemorrhoid Banding</span></label>
-                                      <label><input type="checkbox" name="what_types_of_the_procedures_you_preform[]" value="Infrared Coagulation" /> <span>Infrared Coagulation</span></label>
-                                      <label><input type="checkbox" name="what_types_of_the_procedures_you_preform[]" value="Sclerotherapy" /> <span>Sclerotherapy</span></label>
-                                      <label><input type="checkbox" name="what_types_of_the_procedures_you_preform[]" value="Hemorrhoid stapling" /> <span>Hemorrhoid stapling</span></label>
-                                      <label><input type="checkbox" name="what_types_of_the_procedures_you_preform[]" value="Hemorrhoidectomy" /> <span>Hemorrhoidectomy</span></label>
-                                  </div>
-                              </div>
+                            <div class="row mb-3">
+                                <div class="col-12 question">
+                                    <div class="form-group">
+                                        <label>What is the best phone number to reach you at to take a 5 minute telephone survey?</label>
+                                        <input type="text" class="form-control phone" name="phone_number" value="{{ old('phone_number') }}" />
+                                    </div>
+                                </div>
+                            </div>
 
-                          </div>
-                      </div>
-                      <div class="row mb-3">
-                          <div class="col-12 question">
-                              <div class="form-group">
-                                  <label>Have you ever tried or used banding technics using Rubber band ligation?</label>
-                                  <div class="d-flex">
-                                      <label class="me-3"><input type="radio" name="used_banding_technics_using_rubber_band_ligation" v-model="form.used_banding_technics_using_rubber_band_ligation" value="YES" /> <span>Yes</span></label>
-                                      <label class="me-3"><input type="radio" name="used_banding_technics_using_rubber_band_ligation" v-model="form.used_banding_technics_using_rubber_band_ligation" value="NO" /> <span>No</span></label>
-                                  </div>
-                              </div>
-                              <div v-if="form.used_banding_technics_using_rubber_band_ligation == 'YES'" class="form-group">
-                                  <label>If yes, what is your experience with RBL treatment for hemorrhoids?<sup class="text-danger">*</sup></label>
-                                  <textarea class="form-control" name="experience_with_rbl_treatment_for_hemorrhoids"></textarea>
-                              </div>
-                              <div v-if="form.used_banding_technics_using_rubber_band_ligation == 'NO'" class="form-group">
-                                  <label>If No, Would you like to learn more about hemorroidal treatment option using rubber band ligation?<sup class="text-danger">*</sup></label>
-                                  <div class="d-flex">
-                                      <label class="me-3"><input type="radio" name="interested_to_learn_more_about_hemorroidal_treatment_option_using_rubber_band_ligation" value="YES" /> <span>Yes</span></label>
-                                      <label class="me-3"><input type="radio" name="interested_to_learn_more_about_hemorroidal_treatment_option_using_rubber_band_ligation" value="NO" /> <span>No</span></label>
-                                      <label><input type="radio" name="interested_to_learn_more_about_hemorroidal_treatment_option_using_rubber_band_ligation" value="NOT SURE" /> <span>Not sure</span></label>
-                                  </div>
-                              </div>
+                            <div class="row mb-3">
+                                <div class="col-12 question">
+                                    <div class="form-group">
+                                        <label>Your Name<sup class="text-danger">*</sup></label>
+                                        <input type="text" class="form-control" name="name" value="{{ old('name') }}" required />
+                                    </div>
+                                </div>
+                            </div>
 
-                          </div>
-                      </div>
+                            <div class="row mb-3">
+                                <div class="col-12 question">
+                                    <div class="form-group">
+                                        <label>What state do you practice in:</label>
+                                        <select class="form-control" name="practice_address_state">
+                                            <option value=""></option>
+                                            @foreach(config('constants.us_states') as $stateKey => $stateLabel)
+                                            <option value="{{ $stateKey }}" <?= old('practice_address_state') === $stateKey ? 'selected' : '' ?>>{{ $stateKey }}</option>
+                                            @endforeach
+                                        </select>
+                                    </div>
+                                </div>
+                            </div>
 
-                      <div class="row mb-3">
-                          <div class="col-12 question">
-                              <div class="form-group">
-                                  <label>Would you like to recive free samples of the Snyder HemBand?</label>
-                                  <div class="d-flex">
-                                      <label class="me-3"><input type="radio" name="recive_free_samples_of_the_snyder_hem_band" value="YES" /> <span>Yes</span></label>
-                                      <label class="me-3"><input type="radio" name="recive_free_samples_of_the_snyder_hem_band" value="NO" /> <span>No</span></label>
-                                  </div>
-                              </div>
-                          </div>
-                      </div>
+                            <div class="row mb-3">
+                                <div class="col-12 question">
+                                    <div class="form-group">
+                                        <label>Your email:<sup class="text-danger">*</sup></label>
+                                        <input type="email" class="form-control" name="email" value="{{ old('email') }}" required />
+                                        <small class="text-muted"><i class="fa-duotone fa-circle-info fa-fw"></i> We will use this email address to process your $50 Amazon gift card</small>
+                                    </div>
+                                </div>
+                            </div>
 
-                      <div class="row mb-3">
-                          <div class="col-12 question">
-                              <div class="form-group">
-                                  <label>What would be the best way to contact you?</label>
-                                  <div class="d-flex">
-                                      <label class="me-3"><input type="radio" name="best_way_to_contact_you" value="Phone Call" /> <span>Phone call</span></label>
-                                      <label class="me-3"><input type="radio" name="best_way_to_contact_you" value="Email" /> <span>Email</span></label>
-                                      <label><input type="radio" name="best_way_to_contact_you" value="Text" /> <span>Text</span></label>
-                                  </div>
-                              </div>
-                          </div>
-                      </div>
+                            <div class="row mb-3">
+                                <div class="col-12 question">
+                                    <div class="form-group">
+                                        <label>Preferred time to call:</label>
+                                        <div class="mb-3">
+                                            <label class="me-3 text-muted">Day(s):</label>
+                                            <div class="d-flex flex-wrap mt-1">
+                                                <?php
+                                                $preferred_days_to_call = [
+                                                    'M',
+                                                    'Tu',
+                                                    'W',
+                                                    'Th',
+                                                    'F',
+                                                    'Sa',
+                                                    'Su'
+                                                ];
+                                                ?>
+                                                @foreach($preferred_days_to_call as $day)
+                                                <div class="checkbox me-3">
+                                                    <label>
+                                                        <input type="checkbox" name="preferred_day_to_call[]" value="{{ $day }}">
+                                                        <span class="cr"><i class="cr-icon fa-duotone fa-check fa-fw"></i></span>
+                                                        <span>{{ $day }}</span>
+                                                    </label>
+                                                </div>
+                                                @endforeach
+                                            </div>
+                                        </div>
+                                        <div class="mb-3">
+                                            <label class="me-3 text-muted">Time(s):</label>
+                                            <div class="d-flex flex-wrap mt-1">
+                                                <?php
+                                                $preferred_time_to_call = [
+                                                    '8-10',
+                                                    '10-12',
+                                                    '12-2',
+                                                    '2-4',
+                                                    '4-6'
+                                                ];
+                                                ?>
+                                                @foreach($preferred_time_to_call as $time)
+                                                <div class="checkbox me-3">
+                                                    <label>
+                                                        <input type="checkbox" name="preferred_time_to_call[]" value="{{ $time }}">
+                                                        <span class="cr"><i class="cr-icon fa-duotone fa-check fa-fw"></i></span>
+                                                        <span>{{ $time }}</span>
+                                                    </label>
+                                                </div>
+                                                @endforeach
+                                            </div>
+                                            <small class="text-muted mt-1"><i class="fa-duotone fa-circle-info fa-fw"></i> Your local time</small>
+                                        </div>
+                                    </div>
+                                </div>
+                            </div>
 
-                      <div class="row mb-3">
-                          <div class="col-12 question">
-                              <div class="form-group">
-                                  <label>Preferred time to call:</label>
-                                  <div class="d-flex flex-wrap mb-3">
-                                      <label class="me-3 text-muted">Day(s):</label>
-                                      <label class="me-3"><input type="checkbox" name="preferred_day_to_call[]" value="Monday" /> <span>M</span></label>
-                                      <label class="me-3"><input type="checkbox" name="preferred_day_to_call[]" value="Tuesday" /> <span>Tu</span></label>
-                                      <label class="me-3"><input type="checkbox" name="preferred_day_to_call[]" value="Wednesday" /> <span>W</span></label>
-                                      <label class="me-3"><input type="checkbox" name="preferred_day_to_call[]" value="Thursday" /> <span>Th</span></label>
-                                      <label class="me-3"><input type="checkbox" name="preferred_day_to_call[]" value="Friday" /> <span>F</span></label>
-                                      <label class="me-3"><input type="checkbox" name="preferred_day_to_call[]" value="Saturday" /> <span>Sa</span></label>
-                                      <label class="me-3"><input type="checkbox" name="preferred_day_to_call[]" value="Sunday" /> <span>Su</span></label>
-                                  </div>
-                                  <div class="d-flex flex-wrap mb-3">
-                                      <label class="me-3 text-muted">Time(s) <small>(your local time)</small>:</label>
-                                      <label class="me-3"><input type="checkbox" name="preferred_time_to_call[]" value="8-10" /> <span>8-10</span></label>
-                                      <label class="me-3"><input type="checkbox" name="preferred_time_to_call[]" value="10-12" /> <span>10-12</span></label>
-                                      <label class="me-3"><input type="checkbox" name="preferred_time_to_call[]" value="12-2" /> <span>12-2</span></label>
-                                      <label class="me-3"><input type="checkbox" name="preferred_time_to_call[]" value="2-4" /> <span>2-4</span></label>
-                                      <label class="me-3"><input type="checkbox" name="preferred_time_to_call[]" value="4-6" /> <span>4-6</span></label>
-                                  </div>
-                              </div>
-                          </div>
-                      </div>
 
-                      <div class="row mb-3">
-                          <div class="col-12 question">
-                              <div class="form-group">
-                                  <label>Your comments</label>
-                                  <textarea name="your_comments" class="form-control"></textarea>
-                              </div>
-                          </div>
-                      </div>
 
-                      <div class="row mt-3">
-                          <div class="col-md-12">
-                              <div class="form-group mb-4">
-                                  {!! htmlFormSnippet() !!}
-                                  @error('g-recaptcha-response')
-                                  <small class="text-danger"><i class="fas fa-exclamation-triangle mr-2"></i>Invalid</small>
-                                  @enderror
-                              </div>
-                          </div>
-                          <div class="col-12">
-                              <button type="submit" class="btn btn-pry w-100 py-3">SUBMIT</button>
-                          </div>
-                      </div>
-                  </form>
-              </div>
-              @endif
-          </div>
-      </div>
+                            <div class="row mt-3">
+                                <div class="col-md-12">
+                                    <div class="form-group mb-4">
+                                        {!! htmlFormSnippet() !!}
+                                        @error('g-recaptcha-response')
+                                        <small class="text-danger"><i class="fas fa-exclamation-triangle mr-2"></i>Invalid</small>
+                                        @enderror
+                                    </div>
+                                </div>
+                                <div class="col-12">
+                                    <button type="submit" class="btn btn-pry w-100 py-3">SUBMIT</button>
+                                </div>
+                            </div>
+                        </form>
+                    </div>
+                    @endif
+                </div>
+            </div>
+        </div>
     </div>
-  </div>
 </div>
 
 <script>
@@ -291,53 +285,15 @@
         data: {
             form: {
                 are_you_a_gastroenterologist: "{{ old('are_you_a_gastroenterologist') }}",
-                years_in_practice: "{{ old('years_in_practice') }}"
+                performs_rubber_band_ligation: "{{ old('performs_rubber_band_ligation') }}"
             }
         },
         methods: {
-            initRangeSlider: function() {
-                var self = this;
-                var slider = document.getElementById('rangeSlider');
-                var format = {
-                    to: function(value) {
-                        return Math.round(value);
-                    },
-                    from: function(value) {
-                        return Math.round(value);
-                    }
-                };
-
-                noUiSlider.create(slider, {
-                    start: 0,
-                    step: 5,
-                    connect: 'lower',
-                    range: {
-                        'min': 0,
-                        'max': 70
-                    },
-                    tooltips: true,
-                    format: format,
-                    pips: {
-                        mode: 'steps',
-                        format: format,
-                    },
-                });
-                slider.noUiSlider.on('update', function(values, handle) {
-                    self.form.years_in_practice = values[0];
-                });
-
-                @if(old('years_in_practice'))
-                    slider.noUiSlider.set(parseInt("{{old('years_in_practice')}}"));
-                @endif
-            },
-            init: function() {
-                this.initRangeSlider();
-            }
+            init: function() {}
         },
         mounted: function() {
             this.init();
         }
     });
 </script>
-
-@endsection
+@endsection