<div class="p-3 border-bottom">
    <div class="row mb-2">
        <div class="col-12">
            <label class="text-secondary mb-0 font-weight-normal font-size-16">Preferred {{$label}}</label>
        </div>
    </div>
    <div class="row mb-2">
        <div class="col-12">
            <label class="text-sm text-secondary mb-1">Business Name</label>
            <input type="text" autocomplete="donotdoit" placeholder="Business Name" id="{{$category}}-pharmacy-search" v-model="{{$category}}PopupItem.data.pharmacyName" class="form-control form-control-sm">
            <div class="suggestions-outer pharmacy-suggestions {{$category}}-pharmacy-suggestions position-absolute d-none"></div>
        </div>
    </div>
    <div class="row mb-2">
        <div class="col-4">
            <label class="text-sm text-secondary mb-1">City</label>
            <input type="text" placeholder="City" v-model="{{$category}}PopupItem.data.pharmacyCity" class="form-control form-control-sm min-width-unset">
        </div>
        <div class="col-2 pl-0">
            <label class="text-sm text-secondary mb-1">State</label>
            <input type="text" placeholder="State" v-model="{{$category}}PopupItem.data.pharmacyState" class="form-control form-control-sm min-width-unset">
        </div>
        <div class="col-3 pl-0">
            <label class="text-sm text-secondary mb-1">Phone</label>
            <input type="text" placeholder="Phone" v-model="{{$category}}PopupItem.data.pharmacyPhone" class="form-control form-control-sm min-width-unset">
        </div>
        <div class="col-3 pl-0">
            <label class="text-sm text-secondary mb-1">Fax</label>
            <input type="text" placeholder="Fax" v-model="{{$category}}PopupItem.data.pharmacyFax" class="form-control form-control-sm min-width-unset">
        </div>
    </div>
    <div class="row mb-2">
        <div class="col-12">
            <label class="text-sm text-secondary mb-1">Address Memo</label>
            <input type="text" placeholder="Address Memo" autocomplete="donotdoit" v-model="{{$category}}PopupItem.data.pharmacyAddressMemo" class="form-control form-control-sm">
        </div>
    </div>
</div>
