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@@ -16,13 +16,65 @@
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margin: 58px 0;
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margin: 58px 0;
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padding: 0 15px;
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padding: 0 15px;
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}
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}
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+
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+ .notify.alert-warning {
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+ background-color: #f9f6ee;
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+ border-color: #ffecb5;
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+ }
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+
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+ .notify i {
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+ font-size: 40px;
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+ }
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+
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+ .checkbox label:after {
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+ content: '';
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+ display: table;
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+ clear: both;
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+ }
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+
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+ .checkbox .cr {
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+ position: relative;
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+ display: inline-block;
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+ border: 1px solid #a9a9a9;
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+ border-radius: .25em;
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+ width: 1.3em;
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+ height: 1.3em;
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+ float: left;
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+ margin-right: .5em;
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+ }
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+
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+ .checkbox .cr .cr-icon {
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+ position: absolute;
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+ font-size: .8em;
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+ line-height: 0;
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+ top: 50%;
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+ left: 15%;
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+ }
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+
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+ .checkbox label input[type="checkbox"] {
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+ display: none;
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+ }
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+
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+ .checkbox label input[type="checkbox"]+.cr>.cr-icon {
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+ opacity: 0;
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+ font-weight: bold;
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+ }
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+
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+ .checkbox label input[type="checkbox"]:checked+.cr>.cr-icon {
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+ opacity: 1;
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+ color: var(--pry-color);
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+ }
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+
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+ .checkbox label input[type="checkbox"]:disabled+.cr {
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+ opacity: .5;
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+ }
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</style>
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</style>
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<div class="bg-light">
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<div class="bg-light">
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<div class="container pt-3">
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<div class="container pt-3">
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<nav class="mb-0">
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<nav class="mb-0">
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<ol class="breadcrumb">
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<ol class="breadcrumb">
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- <li class="breadcrumb-item"><a href="{{route('index')}}"><u>Home</u></a></li>
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- <li class="breadcrumb-item active" aria-current="page">Survey Questions</li>
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+ <li class="breadcrumb-item"><a href="{{ route('index') }}"><u>Home</u></a></li>
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+ <li class="breadcrumb-item active" aria-current="page">Hemorrhoid Treatment Survey</li>
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</ol>
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</ol>
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</nav>
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</nav>
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</div>
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</div>
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@@ -31,258 +83,200 @@
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<div class="container">
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<div class="container">
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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-7 text-center">
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<div class="col-lg-7 text-center">
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- <h5 class="subtitle">Survey Questions</h5>
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+ <h5 class="subtitle">Hemorrhoid Treatment Survey</h5>
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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>
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</div>
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</div>
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</div>
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<div class="container py-4">
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<div class="container py-4">
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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="container shadow p-4">
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- <div class="row justify-content-center">
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- @if(session('success'))
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- <div class="col-12">
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- <div class="alert alert-success" role="alert">
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- <h4 class="alert-heading">Congratulations!!</h4>
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- <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>
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- </div>
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- </div>
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- @else
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- <div id="surveyQuestionsComponent" class="col-md-12">
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- <form action="{{ route('submit-gi-survey-questions') }}" method="POST">
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- @csrf
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- <div class="row mb-3">
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- <div class="col-12">
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- <div class="">
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- <div class="row">
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- <div class="col-md-12 mb-3">
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- <div class="form-group">
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- <label>Name<sup class="text-danger">*</sup></label>
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- <input type="text" class="form-control" name="name" value="{{ old('name') }}" required />
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- </div>
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- </div>
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- <div class="col-md-6 mb-3">
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- <div class="form-group">
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- <label>Email<sup class="text-danger">*</sup></label>
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- <input type="email" class="form-control" name="email" value="{{ old('email') }}" required />
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- <small class="text-muted">(to receive digital gift card)</small>
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- </div>
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- </div>
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- <div class="col-md-6 mb-3">
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- <div class="form-group">
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- <label>Mobile Number</label>
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- <input type="text" class="form-control phone" name="mobile_number" value="{{ old('mobile_number') }}" />
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- </div>
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- </div>
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- </div>
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- <div class="row">
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- <div class="col-md-6 mb-3">
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- <div class="form-group ">
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- <label>Practice Address</label>
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- <input type="text" class="form-control" name="practice_address_line_1" value="{{ old('practice_address_line_1') }}" />
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- </div>
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- </div>
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- <div class="col-md-6 mb-3">
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- <div class="form-group ">
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- <label>Practice Address Street</label>
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- <input type="text" class="form-control" name="practice_address_line_2" value="{{ old('practice_address_line_2') }}" />
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- </div>
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- </div>
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- <div class="col-md-4 mb-3">
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- <div class="form-group ">
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- <label>Practice Address City</label>
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- <input type="text" class="form-control" name="practice_address_city" value="{{ old('practice_address_city') }}" />
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- </div>
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- </div>
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- <div class="col-md-4 mb-3">
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- <div class="form-group">
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- <label>Practice Address State</label>
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- <select class="form-control" name="practice_address_state">
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- <option value=""></option>
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- @foreach(config('constants.us_states') as $stateKey => $stateLabel)
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- <option value="{{ $stateKey }}" <?= old('practice_address_state') === $stateKey ? 'selected':'' ?>>{{ $stateKey }}</option>
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- @endforeach
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- </select>
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- </div>
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- </div>
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- <div class="col-md-4 mb-3">
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- <div class="form-group ">
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- <label>Practice Address Zip Code</label>
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- <input type="text" class="form-control zip" name="practice_address_zip_code" value="{{ old('practice_address_zip_code') }}" />
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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>
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- </div>
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- <div class="row mb-3">
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- <div class="col-12 question">
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- <div class="form-group">
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- <label>Are you a gastroenterologist?</label>
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- <div class="d-flex">
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- <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>
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- <label><input type="radio" name="are_you_a_gastroenterologist" v-model="form.are_you_a_gastroenterologist" value="NO" /> <span>No</span></label>
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- </div>
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- </div>
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- <div v-if="form.are_you_a_gastroenterologist == 'NO'" class="form-group">
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- <label>Your speciality?<sup class="text-danger">*</sup></label>
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- <input type="text" class="form-control" name="your_specialty" value="{{ old('your_specialty') }}" required />
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- </div>
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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="container shadow p-4">
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+ <div class="row">
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+ <div class="col-md-12">
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+ <div class="notify alert alert-warning d-flex flex-column flex-md-row align-items-center" role="alert">
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+ <i class="fa-duotone fa-circle-info fa-fw"></i>
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+ <div class="ms-2 mt-2 mt-md-0">
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+ <div>Are you a <b>gastroenterologist</b> who treats hemorrhoids?</div>
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+ <div>Receive a <b>$50 Amazon Gift Card</b> to Take a 5 Minute Telephone Survey</div>
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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="row justify-content-center">
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+ @if (session('success'))
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+ <div class="col-12">
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+ <div class="alert alert-success" role="alert">
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+ <h4 class="alert-heading">Congratulations!!</h4>
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+ <p>You have successfully completed this survey. Eligible submissions will receive a
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+ digital gift cards in 7 business days to the email provided in the survey. </p>
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+ </div>
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+ </div>
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+ @else
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+ <div id="surveyQuestionsComponent" class="col-md-12">
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+ <form action="{{ route('submit-gi-survey-questions') }}" method="POST">
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+ @csrf
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+
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+ <div class="row mb-3">
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+ <div class="col-12 question">
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+ <div class="form-group">
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+ <label>Are you a gastroenterologist?</label>
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+ <div class="d-flex">
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+ <label class="me-3"><input type="radio" name="are_you_a_gastroenterologist" v-model="form.are_you_a_gastroenterologist" value="YES" />
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+ <span>Yes</span></label>
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+ <label><input type="radio" name="are_you_a_gastroenterologist" v-model="form.are_you_a_gastroenterologist" value="NO" />
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+ <span>No</span></label>
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+ </div>
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+ </div>
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+ <div v-if="form.are_you_a_gastroenterologist == 'NO'" class="form-group">
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+ <label>Your speciality?<sup class="text-danger">*</sup></label>
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+ <input type="text" class="form-control" name="your_specialty" value="{{ old('your_specialty') }}" required />
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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>
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- <div class="row mb-3">
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- <div class="col-12 question">
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- <div class="form-group">
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- <label>Years in the practice</label>
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- <div id="rangeSlider" class="noUiSlider"></div>
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- <input type="hidden" name="years_in_practice" :value="form.years_in_practice" />
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- </div>
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+ <div class="row mb-3">
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+ <div class="col-12 question">
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+ <div class="form-group">
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+ <label>How many patients per week, on average, do you see who have hemorrhoids?</label>
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+ <input type="number" class="form-control" name="number_of_patients_per_week" value="{{ old('number_of_patients_per_week') }}" />
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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>
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- <div class="row mb-3">
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- <div class="col-12 question">
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- <div class="form-group">
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- <label>Where do you perform your regular procedures?</label>
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- <div class="d-flex flex-column">
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- <label><input type="checkbox" name="where_do_you_perform_regular_procedures[]" value="Office"> <span>Office</span></label>
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- <label><input type="checkbox" name="where_do_you_perform_regular_procedures[]" value="Endoscopy Center"> <span>Endoscopy Center</span></label>
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- <label><input type="checkbox" name="where_do_you_perform_regular_procedures[]" value="ASC"> <span>ASC</span></label>
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- <label><input type="checkbox" name="where_do_you_perform_regular_procedures[]" value="Hospital"> <span>Hospital</span></label>
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- </div>
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- </div>
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+ <div class="row mb-3">
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+ <div class="col-12 question">
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+ <div class="form-group">
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+ <label>Do you currently perform rubber band ligation (RBL) for hemorrhoid treatment?</label>
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+ <div class="d-flex">
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+ <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>
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+ <label><input type="radio" name="performs_rubber_band_ligation" v-model="form.performs_rubber_band_ligation" value="NO" /> <span>No</span></label>
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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>
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- </div>
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- <div class="row mb-3">
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- <div class="col-12 question">
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- <div class="form-group">
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- <label>Do you perform any procedures for the Hemorrhoids?</label>
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- <div class="d-flex">
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- <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>
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- <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>
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- </div>
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- </div>
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- <div v-if="form.do_you_perform_any_procedures_for_the_hemorrhoids == 'YES'" class="form-group">
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- <label>If yes, what types of the procedures you preform?<sup class="text-danger">*</sup></label>
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- <div class="d-flex flex-column">
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- <label><input type="checkbox" name="what_types_of_the_procedures_you_preform[]" value="Hemorrhoid Banding" /> <span>Hemorrhoid Banding</span></label>
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- <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>
|
|
|
|
|
</div>
|
|
</div>
|
|
|
|
|
|
|
|
<script>
|
|
<script>
|
|
@@ -291,53 +285,15 @@
|
|
|
data: {
|
|
data: {
|
|
|
form: {
|
|
form: {
|
|
|
are_you_a_gastroenterologist: "{{ old('are_you_a_gastroenterologist') }}",
|
|
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: {
|
|
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() {
|
|
mounted: function() {
|
|
|
this.init();
|
|
this.init();
|
|
|
}
|
|
}
|
|
|
});
|
|
});
|
|
|
</script>
|
|
</script>
|
|
|
-
|
|
|
|
|
-@endsection
|
|
|
|
|
|
|
+@endsection
|
