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@@ -7,6 +7,7 @@
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.text-success-light {
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color: #70bb70;
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}
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+
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.form-group label {
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font-weight: 500;
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}
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@@ -123,9 +124,8 @@
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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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+ <h4 class="alert-heading">Thank you!</h4>
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+ <p>We have received your form submission and will process it promptly.</p>
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</div>
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</div>
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@else
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@@ -197,17 +197,27 @@
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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>What is the best phone number to reach you at to take a 5 minute telephone survey?</label>
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- <input type="text" class="form-control phone" name="phone_number" value="{{ old('phone_number') }}" />
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+ <label>What is the best phone number to reach you at to take a 5 minute telephone survey?<sup class="text-danger">*</sup></label>
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+ <input type="tel" class="form-control" name="phone_number" value="{{ old('phone_number') }}" required />
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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>Your 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 class="row">
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+ <div class="col-md-6">
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+ <div class="form-group">
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+ <label>Your First Name<sup class="text-danger">*</sup></label>
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+ <input type="text" class="form-control" name="first_name" value="{{ old('first_name') }}" required />
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+ </div>
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+ </div>
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+ <div class="col-md-6">
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+ <div class="form-group">
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+ <label>Your Last Name<sup class="text-danger">*</sup></label>
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+ <input type="text" class="form-control" name="last_name" value="{{ old('last_name') }}" 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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@@ -215,7 +225,7 @@
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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>What state do you practice in:</label>
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+ <label>What state do you practice in?</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 => $stateLabel)
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@@ -270,11 +280,13 @@
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<div class="d-flex flex-column flex-md-row flex-wrap mt-1">
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<?php
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$preferred_time_to_call = [
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- '8-10',
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- '10-12',
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- '12-2',
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- '2-4',
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- '4-6'
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+ '6-8 am',
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+ '8-10 am',
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+ '10-12 pm',
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+ '12-2 pm',
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+ '2-4 pm',
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+ '4-6 pm',
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+ '6-8 pm'
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];
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?>
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@foreach($preferred_time_to_call as $time)
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@@ -287,6 +299,9 @@
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</div>
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@endforeach
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</div>
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+ <div class="mt-3">
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+ <input type="text" class="form-control" name="any_other_special_time" value="{{ old('any_other_special_time') }}" placeholder="Any other special time" />
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+ </div>
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<small class="text-muted mt-1"><i class="fa-duotone fa-circle-info fa-fw"></i> Your local time</small>
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</div>
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</div>
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