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@@ -12,18 +12,23 @@
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@endif
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<div class="form-group mb-3">
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- <input type="text" name="nameFirst" class="form-control" placeholder="First Name" value="{{ request()->old('nameFirst') }}">
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+ <label class="text--secondary small mb-1 font-weight-normal">First Name *</label>
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+ <input type="text" name="nameFirst" class="form-control" placeholder="First Name" value="{{ request()->old('nameFirst') }}" required>
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</div>
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<div class="form-group mb-3">
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- <input type="text" name="nameLast" class="form-control" placeholder="Last Name" value="{{ request()->old('nameLast') }}">
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+ <label class="text--secondary small mb-1 font-weight-normal">Last Name *</label>
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+ <input type="text" name="nameLast" class="form-control" placeholder="Last Name" value="{{ request()->old('nameLast') }}" required>
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</div>
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<div class="form-group mb-3">
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- <input type="date" name="dob" class="form-control" placeholder="Date of Birth" value="{{ request()->old('dob') }}">
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+ <label class="text--secondary small mb-1 font-weight-normal">Date of Birth *</label>
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+ <input type="date" name="dob" class="form-control" placeholder="Date of Birth" value="{{ request()->old('dob') }}" required>
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</div>
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<div class="form-group mb-3">
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- <input type="text" name="medicareNumber" class="form-control" placeholder="Medicare Number" value="{{ request()->old('medicareNumber') }}">
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+ <label class="text--secondary small mb-1 font-weight-normal">Medicare Number *</label>
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+ <input type="text" name="medicareNumber" class="form-control" placeholder="Medicare Number" value="{{ request()->old('medicareNumber') }}" required>
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</div>
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<div class="form-group mb-3">
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+ <label class="text--secondary small mb-1 font-weight-normal">Phone Number</label>
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<input type="tel" name="phoneNumber" class="form-control" placeholder="Phone Number" value="{{ request()->old('phoneNumber') }}">
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</div>
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<button type="submit" class="btn btn-primary btn-block mx-auto w-50 mt-4 mb-2">Check In</button>
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