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@extends('layouts.app') @section('title') Refer Now @endsection @section('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="{{ config('global.practices_upload') }}{{ $practice->profile_name }}" alt="image" class="img-fluid"> </div> <h4 class="devonshire-heading">{{ $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="{{ route('refer-now') }}" enctype="multipart/form-data"> @csrf <input type="hidden" name="to_practice" id="to_practice" value="{{ $practice->id }}"> @include('layouts.flash-message') <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="{{ old('your_first_name') }}" class="form-control @error('your_first_name') is-invalid @enderror" placeholder="Enter First Name" required> @error('your_first_name') <span class="invalid-feedback" role="alert"> <strong>{{str_replace('your ', ' ', $message)}}</strong> </span> @enderror </div> <div class="referral-input-field"> <label class="label-text">Last Name</label> <input type="text" name="your_last_name" value="{{ old('your_last_name') }}" class="form-control @error('your_last_name') is-invalid @enderror" placeholder="Enter Last Name" required> @error('your_last_name') <span class="invalid-feedback" role="alert"> <strong>{{str_replace('your ', ' ', $message)}}</strong> </span> @enderror </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="{{ old('your_email') }}" class="form-control @error('your_email') is-invalid @enderror" placeholder="Enter Email" pattern="[^@]+@[^@]+\.[a-zA-Z]{2,6}" required> @error('your_email') <span class="invalid-feedback" role="alert"> <strong>{{str_replace('your ', ' ', $message)}}</strong> </span> @enderror </div> <div class="referral-input-field"> <label class="label-text">Phone</label> <input type="text" name="your_phone" value="{{ old('your_phone') }}" class="form-control @error('your_phone') is-invalid @enderror" placeholder="Enter Phone no" required> @error('your_phone') <span class="invalid-feedback" role="alert"> <strong>{{str_replace('your ', ' ', $message)}}</strong> </span> @enderror </div> </div> <div class="referral-flex-field"> <div class="referral-input-field"> <label class="label-text">Practice Name</label> <select class="form-control @error('your_practice_id') is-invalid @enderror" name="your_practice_id" id="practice_id" required> <option value="">Select Practice</option> @foreach ($practices as $practice) <option {{ old('your_practice_id') == $practice->id ? 'selected' : '' }} value="{{ $practice->id }}"> {{ $practice->name }} </option> @endforeach </select> @error('your_practice_id') <span class="invalid-feedback" role="alert"> <strong>{{str_replace('your ', ' ', $message)}}</strong> </span> @enderror </div> <div class="referral-input-field"> <label class="label-text">Job Title</label> <select class="form-control @error('your_job_id') is-invalid @enderror" name="your_job_id" id="job_id" required> <option value="">Select Job Title</option> @foreach ($jobTitles as $jobTitle) <option {{ old('your_job_id') == $jobTitle->id ? 'selected' : '' }} value="{{ $jobTitle->id }}"> {{ $jobTitle->title }} </option> @endforeach </select> @error('your_job_id') <span class="invalid-feedback" role="alert"> <strong>{{str_replace('your ', ' ', $message)}}</strong> </span> @enderror </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="{{ old('your_address') }}" class="form-control @error('your_address') is-invalid @enderror" placeholder="Street address" required> @error('your_address') <span class="invalid-feedback" role="alert"> <strong>{{str_replace('your ', ' ', $message)}}</strong> </span> @enderror </div> <div class="referral-input-field"> <label class="label-text">&nbsp</label> <input type="text" name="your_address_2" value="{{ old('your_]address_2') }}" class="form-control @error('your_address_2') is-invalid @enderror" placeholder="Street address line 2"> @error('your_address_2') <span class="invalid-feedback" role="alert"> <strong>{{str_replace('your ', ' ', $message)}}</strong> </span> @enderror </div> </div> <div class="referral-flex-field"> <div class="referral-input-field"> <input type="text" name="your_city" value="{{ old('your_city') }}" class="form-control @error('your_city') is-invalid @enderror" placeholder="City" required> @error('your_city') <span class="invalid-feedback" role="alert"> <strong>{{str_replace('your ', ' ', $message)}}</strong> </span> @enderror </div> <div class="referral-input-field"> <input type="text" name="your_zip_code" value="{{ old('your_zip_code') }}" class="form-control @error('your_zip_code') is-invalid @enderror" placeholder="Postcode" required> @error('your_zip_code') <span class="invalid-feedback" role="alert"> <strong>{{str_replace('your ', ' ', $message)}}</strong> </span> @enderror </div> <div class="referral-input-field"> <input type="text" name="your_country" value="{{ old('your_country') }}" class="form-control @error('your_country') is-invalid @enderror" placeholder="Country" required> @error('your_country') <span class="invalid-feedback" role="alert"> <strong>{{str_replace('your ', ' ', $message)}}</strong> </span> @enderror </div> </div> {{-- <div class="referral-flex-field"> <div class="referral-input-field"> <label class="label-text">First Name</label> <input type="text" class="form-control" value="{{ $user->first_name }}" placeholder="First Name" readonly> </div> <div class="referral-input-field"> <label class="label-text">Last Name</label> <input type="text" class="form-control" value="{{ $user->last_name }}" placeholder="Last Name" readonly> </div> </div> <div class="referral-flex-field"> <div class="referral-input-field"> <label class="label-text">Address</label> <input type="text" class="form-control" value="{{ $userDetail->address }}" placeholder="Address" readonly> </div> <div class="referral-input-field"> <label class="label-text">Postcode</label> <input type="text" class="form-control" value="{{ $userDetail->zip_code }}" placeholder="Postcode" readonly> </div> </div> <div class="referral-flex-field"> <div class="referral-input-field"> <label class="label-text">Email</label> <input type="text" class="form-control" value="{{ $user->email }}" placeholder="Email" readonly> </div> <div class="referral-input-field"> <label class="label-text">Phone</label> <input type="text" class="form-control" value="{{ $userDetail->phone }}" placeholder="Phone" readonly> </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 @error('referring_dentist') is-invalid @enderror" value="{{ old('referring_dentist') }}" required name="referring_dentist"> @error('referring_dentist') <span class="invalid-feedback" role="alert"> <strong>{{ $message }}</strong> </span> @enderror </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 @error('first_name') is-invalid @enderror" value="{{ old('first_name') }}" name="first_name" placeholder="First Name" required> @error('first_name') <span class="invalid-feedback" role="alert"> <strong>{{ $message }}</strong> </span> @enderror </div> <div class="referral-input-field"> <label class="label-text">Last Name</label> <input type="text" class="form-control @error('last_name') is-invalid @enderror" value="{{ old('last_name') }}" name="last_name" placeholder="Last Name" required> @error('last_name') <span class="invalid-feedback" role="alert"> <strong>{{ $message }}</strong> </span> @enderror </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 @error('date_of_birth') is-invalid @enderror" value="{{ old('date_of_birth') }}" name="date_of_birth" placeholder="Day of Birth" required> @error('date_of_birth') <span class="invalid-feedback" role="alert"> <strong>{{ $message }}</strong> </span> @enderror </div> <div class="referral-input-field"> <label class="label-text">Phone</label> <input type="text" class="form-control @error('phone') is-invalid @enderror" value="{{ old('phone') }}" name="phone" placeholder="Phone" required> @error('phone') <span class="invalid-feedback" role="alert"> <strong>{{ $message }}</strong> </span> @enderror </div> </div> <div class="referral-flex-field"> <div class="referral-input-field"> <label class="label-text">Address</label> <input type="text" class="form-control @error('address') is-invalid @enderror" value="{{ old('address') }}" name="address" placeholder="Address" required> @error('address') <span class="invalid-feedback" role="alert"> <strong>{{ $message }}</strong> </span> @enderror </div> <div class="referral-input-field"> <label class="label-text">Email</label> <input type="text" class="form-control @error('email') is-invalid @enderror" value="{{ old('email') }}" name="email" placeholder="Email" required> @error('email') <span class="invalid-feedback" role="alert"> <strong>{{ $message }}</strong> </span> @enderror </div> </div> </div> <div class="text-area-boxes"> <h6 class="referral-detail-heading">Treatment Information</h6> <div class="select-treatment"> <label class="label-text">Treatments</label> <select name="treatment_type" id="treatment_type" class="form-control @error('treatment_type') is-invalid @enderror" required> <option value="">Select Treatment</option> @foreach ($treatments as $treatment) <option value="{{ $treatment->id }}" {{ old('treatment_type') == $treatment->id ? 'selected' : '' }}>{{ $treatment->title }}</option> @endforeach </select> @error('treatment_type') <span class="invalid-feedback" role="alert"> <strong>{{ $message }}</strong> </span> @enderror </div> <div class="text-area-border"> <label class="label-text">Referral notes</label> <textarea class="form-control @error('referral_notes') is-invalid @enderror" cols="4" rows="10" name="referral_notes" placeholder="Referral notes (specify nhs or private if applicable)">{{ old('referral_notes') }}</textarea> @error('referral_notes') <span class="invalid-feedback" role="alert"> <strong>{{ $message }}</strong> </span> @enderror </div> <div class="text-area-border"> <label class="label-text">Medical history</label> <textarea class="form-control @error('medical_history') is-invalid @enderror" cols="4" rows="10" name="medical_history" placeholder="Medical history">{{ old('medical_history') }}</textarea> @error('medical_history') <span class="invalid-feedback" role="alert"> <strong>{{ $message }}</strong> </span> @enderror </div> <div class="file-upload-opt"> <div class="custom-file"> <label class="label-text">Supporting files</label> <input type="file" class="custom-file-input form-control @if($errors->has('file_name.')) is-invalid @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> @if ($errors->has('file_name.')) <span class="invalid-feedback" role="alert"> <strong>{{ $errors->first('file_name.') }}</strong> </span> @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"> @error('g-recaptcha-response') <span class="text-danger" role="alert"> <strong>{{ $message }}</strong> </span> @enderror </div> </div> {{-- <div class="text-area-border">--}} {{-- <label class="label-text">Recipients Emails</label><br>--}} {{-- <small>Please Choose from the following</small>--}} {{-- <div class="c-chk-box form-group">--}} {{-- <input type="checkbox" id="practice_email" checked value="{{ $practice->email }}"--}} {{-- name="emails[]">--}} {{-- <label for="practice_email">{{ $practice->email }} (Practice Email)</label>--}} {{-- </div>--}} {{-- <small>Practice Users</small>--}} {{-- @if(count($practice->users) > 0)--}} {{-- @foreach($practice->users as $key => $user)--}} {{-- <div class="c-chk-box form-group">--}} {{-- <input type="checkbox" id="{{ $key }}" value="{{ $user->email }}"--}} {{-- name="emails[]">--}} {{-- <label for="{{ $key }}">{{ $user->email }}</label>--}} {{-- </div>--}} {{-- @endforeach--}} {{-- @else--}} {{-- <br>--}} {{-- <b>No user associated</b>--}} {{-- @endif--}} {{-- </div>--}} {{-- <div class="text-area-border">--}} {{-- <label class="label-text">Send Emails to Other Users</label><br>--}} {{-- <small>Multiple emails can be send by using a comma between emails.</small>--}} {{-- <div class="referral-input-field">--}} {{-- <input type="text" class="form-control w-25" name="other_emails" placeholder="abc@email.com,xyz@email.com">--}} {{-- </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 --> @endsection

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