Файловый менеджер

Файловый менеджер - Редактировать - /home/clickysoft/public_html/rgr.clickysoft.net/storage/framework/views/507e7ef3c051994b7c152359a3bdea517941490d.php

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<?php $__env->startSection('title'); ?> Refer Now <?php $__env->stopSection(); ?> <?php $__env->startSection('content'); ?> <!-- BANNER SECTION BEGIN --> <section class="search-banner search-referral-banner"> <div class="container-fluid"> <div class="row"> <div class="col-md-12 col-sm-12 col-12"> </div> </div> </div> </section> <!-- BANNER SECTION END --> <!-- REFERRAL SECTION BEGIN --> <section class="search-referral-sec"> <div class="container-fluid"> <div class="row"> <div class="col-md-3 col-sm-6 col-12"> <div class="referral-img"> <h6 class="referrl-img-heading">Referral</h6> <div class="referral-img-logo"> <div class="referral-logo-img"> <img src="<?php echo e(config('global.practices_upload')); ?><?php echo e($practice->profile_name); ?>" alt="image" class="img-fluid"> </div> <h4 class="devonshire-heading"><?php echo e($practice->name); ?></h4> </div> </div> </div> <div class="col-md-9 col-sm-10 col-12"></div> </div> <div class="row"> <div class="col-md-12 col-sm-12 col-12"> <form method="POST" id="referNowForm" action="<?php echo e(route('refer-now')); ?>" enctype="multipart/form-data"> <?php echo csrf_field(); ?> <input type="hidden" name="to_practice" id="to_practice" value="<?php echo e($practice->id); ?>"> <?php echo $__env->make('layouts.flash-message', \Illuminate\Support\Arr::except(get_defined_vars(), ['__data', '__path']))->render(); ?> <div class="search-referral-form-fields"> <small class="referral-small-text">Fields marked with an * are required</small> <h6 class="referral-detail-heading">Referring Details</h6> <div class="referral-flex-field"> <div class="referral-input-field"> <label class="label-text">First Name</label> <input type="text" name="your_first_name" value="<?php echo e(old('your_first_name')); ?>" class="form-control <?php $__errorArgs = ['your_first_name']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> is-invalid <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?>" placeholder="Enter First Name" required> <?php $__errorArgs = ['your_first_name']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> <span class="invalid-feedback" role="alert"> <strong><?php echo e(str_replace('your ', ' ', $message)); ?></strong> </span> <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?> </div> <div class="referral-input-field"> <label class="label-text">Last Name</label> <input type="text" name="your_last_name" value="<?php echo e(old('your_last_name')); ?>" class="form-control <?php $__errorArgs = ['your_last_name']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> is-invalid <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?>" placeholder="Enter Last Name" required> <?php $__errorArgs = ['your_last_name']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> <span class="invalid-feedback" role="alert"> <strong><?php echo e(str_replace('your ', ' ', $message)); ?></strong> </span> <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?> </div> </div> <div class="referral-flex-field"> <div class="referral-input-field"> <label class="label-text">Email</label> <input type="email" name="your_email" value="<?php echo e(old('your_email')); ?>" class="form-control <?php $__errorArgs = ['your_email']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> is-invalid <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?>" placeholder="Enter Email" pattern="[^@]+@[^@]+\.[a-zA-Z]{2,6}" required> <?php $__errorArgs = ['your_email']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> <span class="invalid-feedback" role="alert"> <strong><?php echo e(str_replace('your ', ' ', $message)); ?></strong> </span> <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?> </div> <div class="referral-input-field"> <label class="label-text">Phone</label> <input type="text" name="your_phone" value="<?php echo e(old('your_phone')); ?>" class="form-control <?php $__errorArgs = ['your_phone']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> is-invalid <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?>" placeholder="Enter Phone no" required> <?php $__errorArgs = ['your_phone']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> <span class="invalid-feedback" role="alert"> <strong><?php echo e(str_replace('your ', ' ', $message)); ?></strong> </span> <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?> </div> </div> <div class="referral-flex-field"> <div class="referral-input-field"> <label class="label-text">Practice Name</label> <select class="form-control <?php $__errorArgs = ['your_practice_id']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> is-invalid <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?>" name="your_practice_id" id="practice_id" required> <option value="">Select Practice</option> <?php $__currentLoopData = $practices; $__env->addLoop($__currentLoopData); foreach($__currentLoopData as $practice): $__env->incrementLoopIndices(); $loop = $__env->getLastLoop(); ?> <option <?php echo e(old('your_practice_id') == $practice->id ? 'selected' : ''); ?> value="<?php echo e($practice->id); ?>"> <?php echo e($practice->name); ?> </option> <?php endforeach; $__env->popLoop(); $loop = $__env->getLastLoop(); ?> </select> <?php $__errorArgs = ['your_practice_id']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> <span class="invalid-feedback" role="alert"> <strong><?php echo e(str_replace('your ', ' ', $message)); ?></strong> </span> <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?> </div> <div class="referral-input-field"> <label class="label-text">Job Title</label> <select class="form-control <?php $__errorArgs = ['your_job_id']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> is-invalid <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?>" name="your_job_id" id="job_id" required> <option value="">Select Job Title</option> <?php $__currentLoopData = $jobTitles; $__env->addLoop($__currentLoopData); foreach($__currentLoopData as $jobTitle): $__env->incrementLoopIndices(); $loop = $__env->getLastLoop(); ?> <option <?php echo e(old('your_job_id') == $jobTitle->id ? 'selected' : ''); ?> value="<?php echo e($jobTitle->id); ?>"> <?php echo e($jobTitle->title); ?> </option> <?php endforeach; $__env->popLoop(); $loop = $__env->getLastLoop(); ?> </select> <?php $__errorArgs = ['your_job_id']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> <span class="invalid-feedback" role="alert"> <strong><?php echo e(str_replace('your ', ' ', $message)); ?></strong> </span> <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?> </div> </div> <div class="referral-flex-field"> <div class="referral-input-field"> <label class="label-text">Address</label> <input type="text" name="your_address" value="<?php echo e(old('your_address')); ?>" class="form-control <?php $__errorArgs = ['your_address']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> is-invalid <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?>" placeholder="Street address" required> <?php $__errorArgs = ['your_address']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> <span class="invalid-feedback" role="alert"> <strong><?php echo e(str_replace('your ', ' ', $message)); ?></strong> </span> <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?> </div> <div class="referral-input-field"> <label class="label-text">&nbsp</label> <input type="text" name="your_address_2" value="<?php echo e(old('your_]address_2')); ?>" class="form-control <?php $__errorArgs = ['your_address_2']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> is-invalid <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?>" placeholder="Street address line 2"> <?php $__errorArgs = ['your_address_2']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> <span class="invalid-feedback" role="alert"> <strong><?php echo e(str_replace('your ', ' ', $message)); ?></strong> </span> <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?> </div> </div> <div class="referral-flex-field"> <div class="referral-input-field"> <input type="text" name="your_city" value="<?php echo e(old('your_city')); ?>" class="form-control <?php $__errorArgs = ['your_city']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> is-invalid <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?>" placeholder="City" required> <?php $__errorArgs = ['your_city']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> <span class="invalid-feedback" role="alert"> <strong><?php echo e(str_replace('your ', ' ', $message)); ?></strong> </span> <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?> </div> <div class="referral-input-field"> <input type="text" name="your_zip_code" value="<?php echo e(old('your_zip_code')); ?>" class="form-control <?php $__errorArgs = ['your_zip_code']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> is-invalid <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?>" placeholder="Postcode" required> <?php $__errorArgs = ['your_zip_code']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> <span class="invalid-feedback" role="alert"> <strong><?php echo e(str_replace('your ', ' ', $message)); ?></strong> </span> <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?> </div> <div class="referral-input-field"> <input type="text" name="your_country" value="<?php echo e(old('your_country')); ?>" class="form-control <?php $__errorArgs = ['your_country']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> is-invalid <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?>" placeholder="Country" required> <?php $__errorArgs = ['your_country']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> <span class="invalid-feedback" role="alert"> <strong><?php echo e(str_replace('your ', ' ', $message)); ?></strong> </span> <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?> </div> </div> <div class="referral-flex-field"> <div class="referral-input-field"> <label class="label-text">Name of Referring Dentist</label> <input type="text" class="form-control <?php $__errorArgs = ['referring_dentist']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> is-invalid <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?>" value="<?php echo e(old('referring_dentist')); ?>" required name="referring_dentist"> <?php $__errorArgs = ['referring_dentist']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> <span class="invalid-feedback" role="alert"> <strong><?php echo e($message); ?></strong> </span> <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?> </div> </div> </div> <div class="search-referral-form-fields"> <small class="referral-small-text">Fields marked with an are required</small> <h6 class="referral-detail-heading">Patient Details</h6> <div class="referral-flex-field"> <div class="referral-input-field"> <label class="label-text">First Name</label> <input type="text" class="form-control <?php $__errorArgs = ['first_name']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> is-invalid <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?>" value="<?php echo e(old('first_name')); ?>" name="first_name" placeholder="First Name" required> <?php $__errorArgs = ['first_name']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> <span class="invalid-feedback" role="alert"> <strong><?php echo e($message); ?></strong> </span> <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?> </div> <div class="referral-input-field"> <label class="label-text">Last Name</label> <input type="text" class="form-control <?php $__errorArgs = ['last_name']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> is-invalid <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?>" value="<?php echo e(old('last_name')); ?>" name="last_name" placeholder="Last Name" required> <?php $__errorArgs = ['last_name']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> <span class="invalid-feedback" role="alert"> <strong><?php echo e($message); ?></strong> </span> <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?> </div> </div> <div class="referral-flex-field"> <div class="referral-input-field"> <label class="label-text">Date of Birth</label> <input type="text" onfocus="(this.type='date')" min="1900-01-01" max="3000-12-31" class="form-control <?php $__errorArgs = ['date_of_birth']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> is-invalid <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?>" value="<?php echo e(old('date_of_birth')); ?>" name="date_of_birth" placeholder="Day of Birth" required> <?php $__errorArgs = ['date_of_birth']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> <span class="invalid-feedback" role="alert"> <strong><?php echo e($message); ?></strong> </span> <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?> </div> <div class="referral-input-field"> <label class="label-text">Phone</label> <input type="text" class="form-control <?php $__errorArgs = ['phone']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> is-invalid <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?>" value="<?php echo e(old('phone')); ?>" name="phone" placeholder="Phone" required> <?php $__errorArgs = ['phone']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> <span class="invalid-feedback" role="alert"> <strong><?php echo e($message); ?></strong> </span> <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?> </div> </div> <div class="referral-flex-field"> <div class="referral-input-field"> <label class="label-text">Address</label> <input type="text" class="form-control <?php $__errorArgs = ['address']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> is-invalid <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?>" value="<?php echo e(old('address')); ?>" name="address" placeholder="Address" required> <?php $__errorArgs = ['address']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> <span class="invalid-feedback" role="alert"> <strong><?php echo e($message); ?></strong> </span> <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?> </div> <div class="referral-input-field"> <label class="label-text">Email</label> <input type="text" class="form-control <?php $__errorArgs = ['email']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> is-invalid <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?>" value="<?php echo e(old('email')); ?>" name="email" placeholder="Email" required> <?php $__errorArgs = ['email']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> <span class="invalid-feedback" role="alert"> <strong><?php echo e($message); ?></strong> </span> <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?> </div> </div> </div> <div class="text-area-boxes"> <h6 class="referral-detail-heading">Treatment Information</h6> <div class="select-treatment"> <label class="label-text">Treatments</label> <select name="treatment_type" id="treatment_type" class="form-control <?php $__errorArgs = ['treatment_type']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> is-invalid <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?>" required> <option value="">Select Treatment</option> <?php $__currentLoopData = $treatments; $__env->addLoop($__currentLoopData); foreach($__currentLoopData as $treatment): $__env->incrementLoopIndices(); $loop = $__env->getLastLoop(); ?> <option value="<?php echo e($treatment->id); ?>" <?php echo e(old('treatment_type') == $treatment->id ? 'selected' : ''); ?>><?php echo e($treatment->title); ?></option> <?php endforeach; $__env->popLoop(); $loop = $__env->getLastLoop(); ?> </select> <?php $__errorArgs = ['treatment_type']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> <span class="invalid-feedback" role="alert"> <strong><?php echo e($message); ?></strong> </span> <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?> </div> <div class="text-area-border"> <label class="label-text">Referral notes</label> <textarea class="form-control <?php $__errorArgs = ['referral_notes']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> is-invalid <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?>" cols="4" rows="10" name="referral_notes" placeholder="Referral notes (specify nhs or private if applicable)"><?php echo e(old('referral_notes')); ?></textarea> <?php $__errorArgs = ['referral_notes']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> <span class="invalid-feedback" role="alert"> <strong><?php echo e($message); ?></strong> </span> <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?> </div> <div class="text-area-border"> <label class="label-text">Medical history</label> <textarea class="form-control <?php $__errorArgs = ['medical_history']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> is-invalid <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?>" cols="4" rows="10" name="medical_history" placeholder="Medical history"><?php echo e(old('medical_history')); ?></textarea> <?php $__errorArgs = ['medical_history']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> <span class="invalid-feedback" role="alert"> <strong><?php echo e($message); ?></strong> </span> <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?> </div> <div class="file-upload-opt"> <div class="custom-file"> <label class="label-text">Supporting files</label> <input type="file" class="custom-file-input form-control <?php if($errors->has('file_name.')): ?> is-invalid <?php endif; ?>" name="file_name[]" id="file" multiple onchange="javascript:updateList()"> <label class="custom-file-label " for="file"> <h6 class="upload-heading">Xrays / supporting files</h6> <i class="fa fa-upload" aria-hidden="true"></i> Upload Files </label> <?php if($errors->has('file_name.')): ?> <span class="invalid-feedback" role="alert"> <strong><?php echo e($errors->first('file_name.')); ?></strong> </span> <?php endif; ?> </div> <span class="fs22">For more than one files, please select the files at once</span> <ul id="fileList" class="file-list"></ul> </div> <div class="referral-flex-field"> <div class="referral-input-field"> <?php $__errorArgs = ['g-recaptcha-response']; $__bag = $errors->getBag($__errorArgs[1] ?? 'default'); if ($__bag->has($__errorArgs[0])) : if (isset($message)) { $__messageOriginal = $message; } $message = $__bag->first($__errorArgs[0]); ?> <span class="text-danger" role="alert"> <strong><?php echo e($message); ?></strong> </span> <?php unset($message); if (isset($__messageOriginal)) { $message = $__messageOriginal; } endif; unset($__errorArgs, $__bag); ?> </div> </div> <div class="form-submit-btn"> <button type="submit" class="btn btn-primary">Submit</button> </div> </div> </form> </div> </div> </div> </section> <!-- REFERRAL SECTION END --> <?php $__env->stopSection(); ?> <?php echo $__env->make('layouts.app', \Illuminate\Support\Arr::except(get_defined_vars(), ['__data', '__path']))->render(); ?><?php /PATH /home/clickysoft/public_html/rgr.clickysoft.net/resources/views/refer-now.blade.php ENDPATH/ ?>

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