200 lines
14 KiB
PHP
200 lines
14 KiB
PHP
<!DOCTYPE html>
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<html lang="en">
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<head>
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@include('layouts.shared/title-meta', ['title' => "Register & Signup"])
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@include('layouts.shared/head-css', ["mode" => $mode ?? '', "demo" => $demo ?? ''])
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<link href="{{asset('assets/libs/flatpickr/flatpickr.min.css')}}" rel="stylesheet" type="text/css" />
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</head>
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<body class="loading authentication-bg authentication-bg-pattern">
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<div class="account-pages mt-5 mb-5">
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<div class="container">
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<div class="row justify-content-center">
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<div class="col-md-8">
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<div class="card bg-pattern">
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<div class="card-body p-4">
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<div class="text-center w-75 m-auto">
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<div class="auth-logo">
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<a href="/road/register" class="logo logo-dark text-center">
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<span class="logo-lg">
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<img src="{{asset('/casper_clinic_new/images/logo.png')}}" alt="" height="100">
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</span>
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</a>
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<a href="/road/register" class="logo logo-light text-center">
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<span class="logo-lg">
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<img src="{{asset('/casper_clinic_new/images/logo.png')}}" alt="" height="100">
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</span>
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</a>
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</div>
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<h4>Controlling Asthma in Pediatric Population through Education and Research (CASPER CLINIC)</h4>
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<h5>{{$session->number}}</h5>
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@foreach($session->dates->date as $i => $date)
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<h5>{{date("d M, Y", strtotime($date) )}} <small>{{date("h:iA", strtotime($session->dates->start[$i]) )}}-{{date("h:iA", strtotime($session->dates->end[$i]) )}}</small></h5>
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@endforeach
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</div>
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@if(session('error'))<div class="alert alert-danger">{{ session('error') }}</div>
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<br>@endif
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@if(session('success'))<div class=" alert alert-success">{{ session('success') }}
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</div>
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<br>@endif
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@if (sizeof($errors) > 0)
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<ul>
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@foreach ($errors->all() as $error)
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<li class="text-danger">{{ $error }}</li>
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@endforeach
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</ul>
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@endif
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<h4>Registration Form</h4>
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<form method="POST" action="/register/{{$session->code}}">
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@csrf
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<div class="row mb-3">
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<label for="name" class="col-4 col-xl-3 col-form-label">Doctor’s Name</label>
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<div class="col-8 col-xl-9">
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<input type="text" class="form-control" id="name" name="name" required>
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</div>
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</div>
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<div class="row mb-3">
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<label for="date_of_birth" class="col-4 col-xl-3 col-form-label">Date of Birth</label>
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<div class="col-8 col-xl-9">
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<input type="text" class="form-control datepicker" id="date_of_birth" name="date_of_birth" required>
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</div>
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</div>
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<div class="row mb-3">
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<label for="gender" class="col-4 col-xl-3 col-form-label">Gender</label>
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<div class="col-8 col-xl-9">
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<div class="form-check">
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<input type="radio" id="gender-male" name="gender" class="form-check-input" value="Male" required>
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<label class="form-check-label" for="gender-male">Male</label>
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</div>
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<div class="form-check">
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<input type="radio" id="gender-female" name="gender" class="form-check-input" value="Female" required>
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<label class="form-check-label" for="gender-female">Female</label>
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</div>
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</div>
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</div>
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@include('partials.register-whatsapp-field')
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<div class="row mb-3">
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<label for="alternate_phone" class="col-4 col-xl-3 col-form-label">Alternate Contact Number</label>
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<div class="col-8 col-xl-9">
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<input type="text" class="form-control" id="alternate_phone" name="alternate_phone" required>
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</div>
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</div>
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<div class="row mb-3">
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<label for="email" class="col-4 col-xl-3 col-form-label">Email* (Frequently Used)</label>
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<div class="col-8 col-xl-9">
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<input type="email" class="form-control" id="email" name="email" required>
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</div>
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</div>
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@include('partials.register-location-fields')
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<div class="row mb-3">
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<label for="highlight_qualification" class="col-4 col-xl-3 col-form-label">Qualification</label>
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<div class="col-8 col-xl-9">
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<select class="form-control" id="highlight_qualification" name="highlight_qualification" required>
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<option value="">Select</option>
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<option value="MBBS">MBBS</option>
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<option value="PG Student">PG Student</option>
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<option value="UG Student">UG Student</option>
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<option value="MD">MD</option>
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<option value="DNB">DNB</option>
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<option value="DCh">DCh</option>
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<option value="CPS">CPS</option>
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<option value="Others (Please Specify)">Others (Please Specify)</option>
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</select>
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</div>
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</div>
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<div class="row mb-3">
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<label for="specialization" class="col-4 col-xl-3 col-form-label">Specialty of Practice/Work</label>
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<div class="col-8 col-xl-9">
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<select class="form-control" id="specialization" name="specialization" required>
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<option value="">Select</option>
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<option value="Pediatrician">Pediatrician</option>
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<option value="Post Graduate Student">Post Graduate Student</option>
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<option value="General Practitioner">General Practitioner</option>
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<!-- <option value="Family Physician">Family Physician</option>
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<option value="General Physician">General Physician</option> -->
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<!-- <option value="CPS">CPS</option>
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<option value="MBBS">MBBS</option>
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<option value="PG Student">PG Student</option> -->
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<option value="Others">Others</option>
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</select>
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</div>
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</div>
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<!-- <div class="row mb-3">
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<label for="type_of_setup" class="col-4 col-xl-3 col-form-label">Type of Setup <small>(You may choose multiple options)</small></label>
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<div class="col-8 col-xl-9">
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<div class="form-check">
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<input type="checkbox" class="form-check-input" id="type_of_setup-1" name="type_of_setup[]" value="Private Hospital">
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<label class="form-check-label" for="type_of_setup-1">Private Hospital</label>
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</div>
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<div class="form-check">
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<input type="checkbox" class="form-check-input" id="type_of_setup-2" name="type_of_setup[]" value="Govt. Hospital">
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<label class="form-check-label" for="type_of_setup-2">Govt. Hospital</label>
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</div>
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<div class="form-check">
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<input type="checkbox" class="form-check-input" id="type_of_setup-3" name="type_of_setup[]" value="Private Clinic">
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<label class="form-check-label" for="type_of_setup-3">Private Clinic</label>
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</div>
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<div class="form-check">
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<input type="checkbox" class="form-check-input" id="type_of_setup-4" name="type_of_setup[]" value="Govt. Clinic">
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<label class="form-check-label" for="type_of_setup-4">Govt. Clinic</label>
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</div>
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<div class="form-check">
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<input type="checkbox" class="form-check-input" id="type_of_setup-5" name="type_of_setup[]" value="Teaching Hospital">
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<label class="form-check-label" for="type_of_setup-5">Teaching Hospital</label>
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</div>
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<div class="form-check">
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<input type="checkbox" class="form-check-input" id="type_of_setup-6" name="type_of_setup[]" value="Research Organization">
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<label class="form-check-label" for="type_of_setup-6">Research Organization</label>
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</div>
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<div class="form-check">
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<input type="checkbox" class="form-check-input" id="type_of_setup-7" name="type_of_setup[]" value="NGO">
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<label class="form-check-label" for="type_of_setup-7">NGO</label>
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</div>
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<div class="form-check">
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<input type="checkbox" class="form-check-input" id="type_of_setup-8" value="Others (Please Specify)">
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<label class="form-check-label" for="type_of_setup-8">Others (Please Specify)</label>
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</div>
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</div>
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</div> -->
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<div class="row mb-3">
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<label for="designation" class="col-4 col-xl-3 col-form-label">Designation</label>
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<div class="col-8 col-xl-9">
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<input type="text" class="form-control" id="designation" name="designation" required>
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</div>
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</div>
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<div class="row mb-3">
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<label for="clinic_institute_name" class="col-4 col-xl-3 col-form-label">Name of the Institute</label>
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<div class="col-8 col-xl-9">
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<input type="text" class="form-control" id="clinic_institute_name" name="clinic_institute_name" required>
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</div>
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</div>
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<div class="mb-3">
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<div class="form-check">
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<input type="checkbox" class="form-check-input" id="checkbox-signup" required>
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<label class="form-check-label" for="checkbox-signup">I hereby give consent to receiving further communication from CREST for academic and research purposes</label>
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</div>
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</div>
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<div class="text-center d-grid">
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<button class="btn btn-success" type="submit" style="max-width:30%"> Sign Up </button>
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</div>
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</form>
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</div> <!-- end card-body -->
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</div>
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<!-- end card -->
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</div> <!-- end col -->
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</div>
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<!-- end row -->
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</div>
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<!-- end container -->
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</div>
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<!-- end page -->
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@include('layouts.shared/footer-script')
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@include('partials.register-location-scripts')
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<script src="{{asset('assets/libs/flatpickr/flatpickr.min.js')}}"></script>
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<script type="text/javascript">
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$('.datepicker').flatpickr();
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</script>
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</body>
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</html> |