snyder/resources/views/app/physicians/contact-us.blade.php

@extends('layouts.physicians')
@section('content')

<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"><a href="{{route('physicians.index')}}"><u>Physicians</u></a></li>
                <li class="breadcrumb-item active" aria-current="page">Contact Us</li>
            </ol>
        </nav>
    </div>
</div>
<div class="py-5">
  <div class="container">
    <div class="row justify-content-center">
      <div class="col-lg-7 text-center">
        <h5 class="subtitle">Get In Touch</h5>
        <p>If you have questions about the Snyder HemBand, our training program, or anything else, please contact us anytime. We’ll get back to you as soon as possible, typically within 1 business day.</p>
        <p>If you are already a partner and need assistance, please contact one of the following departments:</p>
        <p class="mb-1"><b>General Information and Ligator Orders: 800.660.2153 x 1011</b></p>
        <p class="mb-1"><b>Practice Support for the CRH O’Regan System: 800.660.2153 x 0</b></p>
      </div>
    </div>
  </div>
</div>
<div class="bg-light">
  <div class="container py-5">
    <div class="row justify-content-center">
      <div class="col-lg-8">
        <h5 class="header">Contact Us</h5>
        <form class="" action="" method="post">
          @csrf
          <label for="">Full Name <span class="text-danger">*</span> </label>
          <div class="row">
            <div class="col-lg-4 form-group mb-4">
              <select class="form-control rounded-0 py-3" required name="prefix">
                <option value="">Select Prefix</option>
                <option value="Dr.">Dr.</option>
                <option value="Mr.">Mr.</option>
                <option value="Mrs.">Mrs.</option>
                <option value="Miss">Miss</option>
                <option value="Ms.">Ms.</option>
                <option value="Prof.">Prof.</option>
              </select>
              @error('prefix')
                <small class="text-warning">{{$message}}</small>
              @enderror
            </div>
            <div class="col-lg-4 form-group mb-4">
              <input type="text" class="form-control rounded-0 py-3" required name="name_first" placeholder="First Name" value="{{ old('name_first') }}">
              @error('name_first')
                <small class="text-warning">{{$message}}</small>
              @enderror
            </div>
            <div class="col-lg-4 form-group mb-4">
              <input type="text" class="form-control rounded-0 py-3" required name="name_last" placeholder="Last Name" value="{{ old('name_last') }}">
              @error('name_last')
                <small class="text-warning">{{$message}}</small>
              @enderror
            </div>
          </div>
          <div class="form-group mb-4">
            <label>Practice Name <span class="text-danger">*</span> </label>
            <input type="text" class="form-control rounded-0 py-3" required name="practice_name" value="{{ old('practice_name') }}">
          </div>
          <div class="form-group mb-4">
            <label>Email <span class="text-danger">*</span> </label>
            <input type="email" class="form-control rounded-0 py-3" required name="email" value="{{ old('email') }}">
          </div>
          <div class="form-group mb-4">
            <label>Phone <span class="text-danger">*</span> </label>
            <input type="tel" class="form-control rounded-0 py-3" required phone name="phone" value="{{ old('phone') }}">
          </div>
          <div class="form-group mb-4">
            <label>Zip / Postal Code <span class="text-danger">*</span> </label>
            <input type="text" class="form-control rounded-0 py-3" required phone name="zip" value="{{ old('zip') }}">
          </div>
          <div class="form-group mb-4">
            <label>How Can We Help You?<span class="text-danger">*</span></label>
            <textarea name="message" class="form-control rounded-0" required rows="6">{{ old('message') }}</textarea>
          </div>
          <button type="submit" class="btn btn-pry w-100 py-3">SUBMIT</button>
        </form>
      </div>
    </div>
  </div>
</div>
@endsection