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@@ -16,6 +16,9 @@
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<h5 class="subtitle">Where can I get the Snyder HemBand System?</h5>
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<h5 class="subtitle">Where can I get the Snyder HemBand System?</h5>
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<p>You’re a simple rubber band away from long-lasting hemorrhoid treatment.</p>
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<p>You’re a simple rubber band away from long-lasting hemorrhoid treatment.</p>
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<p>Over 1,000 physicians across the United States offer hemorrhoid banding to their patients.</p>
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<p>Over 1,000 physicians across the United States offer hemorrhoid banding to their patients.</p>
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+ <div class="alert alert-warning p-3">
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+ <p>Are you a physician or practice administrator that currently offers Snyder HemBand? Please contact us to be added to our directory listing.</p>
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+ </div>
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<div class="row mt-5">
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<div class="row mt-5">
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<div class="col-sm-6 mb-4">
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<div class="col-sm-6 mb-4">
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<h5 class="header m-0">Our Office</h5>
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<h5 class="header m-0">Our Office</h5>
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@@ -45,25 +48,50 @@
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<div class="col-lg-6 bg-grey p-lg-5 p-4 mb-4 offset-lg-1" style="border-bottom:7px solid var(--pry-color);">
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<div class="col-lg-6 bg-grey p-lg-5 p-4 mb-4 offset-lg-1" style="border-bottom:7px solid var(--pry-color);">
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<h4 class="subtitle">Find a Clinic</h4>
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<h4 class="subtitle">Find a Clinic</h4>
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<p class="mb-4">Please complete this brief contact form, and a Patient Care Representative will be in contact with information about trained specialists near you.</p>
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<p class="mb-4">Please complete this brief contact form, and a Patient Care Representative will be in contact with information about trained specialists near you.</p>
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- <form class="" action="" method="post">
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+ <form class="" action="{{ route('submit-find-a-clinic') }}" method="post">
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@csrf
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@csrf
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<div class="row">
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<div class="row">
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<div class="col-lg-6 form-group mb-4">
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<div class="col-lg-6 form-group mb-4">
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- <input type="text" class="form-control rounded-0 py-3" name="fname" placeholder="First Name" required value="">
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+ <input type="text" class="form-control rounded-0 py-3" name="name_first" placeholder="First Name" value="{{ old('name_first') }}" />
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+ @error('name_first')
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+ <small class="text-warning">{{$message}}</small>
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+ @enderror
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</div>
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</div>
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<div class="col-lg-6 form-group mb-4">
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<div class="col-lg-6 form-group mb-4">
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- <input type="text" class="form-control rounded-0 py-3" name="lname" placeholder="Last Name" required value="">
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+ <input type="text" class="form-control rounded-0 py-3" name="name_last" placeholder="Last Name" value="{{ old('name_last') }}" />
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+ @error('name_last')
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+ <small class="text-warning">{{$message}}</small>
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+ @enderror
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</div>
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</div>
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</div>
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</div>
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<div class="form-group mb-4">
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<div class="form-group mb-4">
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- <input type="email" class="form-control rounded-0 py-3" name="email" placeholder="Email Address" required value="">
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+ <input type="email" class="form-control rounded-0 py-3" name="email" placeholder="Email Address" value="{{ old('email') }}" />
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+ @error('email')
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+ <small class="text-warning">{{$message}}</small>
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+ @enderror
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</div>
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</div>
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<div class="form-group mb-4">
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<div class="form-group mb-4">
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- <input type="text" class="form-control rounded-0 py-3" name="phone" placeholder="Phone Number" required value="">
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+ <input type="text" class="form-control rounded-0 py-3" name="phone" placeholder="Phone Number" value="{{ old('phone') }}" />
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+ @error('phone')
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+ <small class="text-warning">{{$message}}</small>
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+ @enderror
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</div>
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</div>
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<div class="form-group mb-4">
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<div class="form-group mb-4">
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- <input type="text" class="form-control rounded-0 py-3" name="zip" placeholder="Zip Code" required value="">
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+ <input type="text" class="form-control rounded-0 py-3" name="zip" placeholder="Zip Code" value="{{ old('zip') }}" />
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+ @error('zip')
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+ <small class="text-warning">{{$message}}</small>
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+ @enderror
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+ </div>
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+ @if($errors->any())
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+ <div class="alert alert-danger fade show" role="alert">
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+ There were errors found!
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+ </div>
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+ @endif
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+ @if(session('success'))
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+ <div class="alert alert-success fade show" role="alert">
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+ {{session('success')}}
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</div>
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</div>
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+ @endif
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<button type="submit" class="btn btn-pry w-100 py-3">Submit</button>
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<button type="submit" class="btn btn-pry w-100 py-3">Submit</button>
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</form>
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</form>
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</div>
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</div>
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