@extends('themes.frontend.layouts.app')
@section('flatpickr') @stop
@section('validate') @stop

@if (isset($dataArr['meta_title']))
@section('page-title'){{ $dataArr['meta_title'] }}@stop
@else
@section('page-title'){{ $dataArr['title'] }}@stop
@endif
@if (isset($dataArr['meta_key']))
@section('meta-keywords'){{ $dataArr['meta_key'] }}@stop
@endif
@if (isset($dataArr['meta_descp']))
@section('meta-description'){{ $dataArr['meta_descp'] }}@stop
@endif
@if (isset($dataArr['image_path']))
@section('meta-image'){{ $dataArr['image_path'] }}@stop
@endif
@if ($dataArr['full_url'])
@section('cur-url'){{ $dataArr['full_url'] }}@stop
@endif

@push('styles')
@if(isset($dataArr['custom_fields']['textarea_4']) && $dataArr['custom_fields']['textarea_4'] && $dataArr['custom_fields']['textarea_4']['value'])
<!--====== START: CUSTOM PAGE CSS from backed the Page ======-->
<style scoped>
		{!! $dataArr['custom_fields']['textarea_4']['value'] !!}
</style>
<!--====== END: CUSTOM PAGE CSS from backed the Page ======-->
@endif
@endpush

@section('content')
<!--====== BANNER PART START ======-->
@include('themes.frontend.includes.breadcrumb',['titleClass'=>'text-white'])
<!--====== BANNER PART ENDS ======-->

<!--==================================================-->
<!-----Start contact Section Style Seven ----->
<!--===================================================-->
@if (isset($dataArr['custom_fields']['editor_1']))
    {!!  app(App\Services\ShortcodeProcessor::class)->process($dataArr['custom_fields']['editor_1']['value']) !!}
@endif

<style>
  a.pq-button-text {
    padding: 12px 30px;
    font-size: 14px;
    font-weight: 600;
    background: var(--primary-color);
    font-family: var(--title-fonts);
    text-transform: uppercase;
    letter-spacing: 0.04em;
    color: var(--white-color);
    display: inline-block;
    border: none;
    width: auto;
    height: auto;
    line-height: 2;
    transition: all 0.5s ease-in-out;
    -moz-transition: all 0.5s ease-in-out;
    -ms-transition: all 0.5s ease-in-out;
    -o-transition: all 0.5s ease-in-out;
    -webkit-transition: all 0.5s ease-in-out;
  }
  a.pq-button-text:hover {
    background: var(--dark-color);
  }
</style>

<section class="appoinment-form  appointment-page pt-pb-130 ">
    <div class="container">
      	<div class="row">
        	<div class="col-xl-12">
          		<div class="appoinment-box">
					<center>
						<h1>ALLISTON PHYSIOTHERAPY &amp; SPORTS REHABILITATION</h1>
					</center>
					@if(session('success'))
						<div class="alert alert-success">{{ session('success') }}</div>
					@endif
                	<div class="row">
						<form action="{{ url('sports-rehabilitation-process') }}" name="new_patient" id="new_patient" method="post" novalidate="novalidate">
							@csrf
							<div class="pq-appointment">
								<div class="row">
									<div class="col-lg-6">
										Name 
										<span class="required text-danger">*</span>		
										<input class="form-control pq-bg-white paitent-name-field" id="" name="name" required="required" type="text"   placeholder="Name"   autocomplete="off" value="{{ old('name') }}">
										@error('name') <span class="text-danger">{{ $message }}</span> @enderror
									</div>                
									<div class="col-lg-6">
										Date Of Birth 
										<span class="required text-danger">*</span>		
										<input class="form-control pq-bg-white paitent-dob-field date_empty" id="" name="dob" required="required" type="date"   placeholder="Date Of Birth"   autocomplete="off" value="{{ old('dob') }}">
										@error('dob') <span class="text-danger">{{ $message }}</span> @enderror
									</div>
									<div class="col-lg-6">
										Injured Area 
										<span class="required text-danger">*</span>		
										<input class="form-control pq-bg-white paitent-name-field" id="" name="injured_area" required="required" type="text"   placeholder=""   autocomplete="off" value="{{ old('injured_area') }}">
										@error('injured_area') <span class="text-danger">{{ $message }}</span> @enderror
									</div> 
									<div class="col-lg-6">
										Assessment Date
										<span class="required text-danger">*</span>		
										<input class="form-control pq-bg-white paitent-dob-field date_empty" id="" name="assessment_date" required="required" type="date"   placeholder=""   autocomplete="off" value="{{ old('assessment_date') }}">
										@error('assessment_date') <span class="text-danger">{{ $message }}</span> @enderror
									</div>
									<div class="col-lg-6">
										Email
										<span class="required text-danger">*</span>		
										<input class="form-control pq-bg-white paitent-name-field" id="" name="email" required="required" type="email"   placeholder=""   autocomplete="off" value="{{ old('email') }}">
										@error('email') <span class="text-danger">{{ $message }}</span> @enderror
									</div> 
									<div class="col-lg-6">
										Address
										<span class="required text-danger">*</span>		
										<input class="form-control pq-bg-white paitent-name-field" id="" name="address" required="required" type="text"   placeholder=""   autocomplete="off" value="{{ old('address') }}">
										@error('address') <span class="text-danger">{{ $message }}</span> @enderror
									</div> 
									<div class="col-lg-6">
										Phone
										<span class="required text-danger">*</span>		
										<input class="form-control pq-bg-white paitent-name-field" id="" name="phone" required="required" type="text"   placeholder=""   autocomplete="off" value="{{ old('phone') }}">
										@error('phone') <span class="text-danger">{{ $message }}</span> @enderror
									</div> 
									<div class="col-lg-12">
										How did you hear about us?
										<input type="checkbox" name="hear_about[]" value="google" {{ in_array('google', old('hear_about', [])) ? 'checked' : '' }}> Google &nbsp; 
										<input type="checkbox" name="hear_about[]" value="friends" {{ in_array('friends', old('hear_about', [])) ? 'checked' : '' }}> Friends &nbsp; 
										<input type="checkbox" name="hear_about[]" value="family" {{ in_array('family', old('hear_about', [])) ? 'checked' : '' }}> Family &nbsp; 
										<input type="checkbox" name="hear_about[]" value="reff_by_doctor" {{ in_array('reff_by_doctor', old('hear_about', [])) ? 'checked' : '' }}> Reff By Doctor &nbsp; 
										<input type="checkbox" name="hear_about[]" value="other" {{ in_array('other', old('hear_about', [])) ? 'checked' : '' }}> Other &nbsp; 
									</div> 
									<div class="col-lg-12">
										If select other, please describe
										<textarea name="hear_about_other">{{ old('hear_about_other') }}</textarea>
									</div>
									<div class="col-lg-6 ">
										<h6 class="text-white">OFFICE USE ONLY</h6>
									</div> 
									<div class="col-lg-12">
										Treatment Plan
										<textarea name="treatment_plan">{{ old('treatment_plan') }}</textarea>
									</div>
			   						<div class="col-lg-12">
										Exercise
										<textarea name="excercise">{{ old('excercise') }}</textarea>
									</div>
								</div>
                				<div class="row">
									<div class="col-lg-4">
                    					<div class="quote_btn pb-4" style="text-align: left;">
											<div class="pq-button-block">
												<a class="pq-button-text me-0" href="waiver"><i class="fas fa-angle-double-left"></i> Back</a>
											</div>
										</div>
                  					</div>
									<div class="col-lg-4">&nbsp;</div>
									<div class="col-lg-4">
										<div class="quote_btn pb-4" style="text-align: right;">
											<div class="pq-button-block">
												<button type="submit" class="pq-button-text me-0" id="send_new_patient" name="send_new_patient">Submit <i class="fas fa-angle-double-right"></i></button>
											</div>
										</div>
									</div>
								</div>
							</div>
   	 					</form>
						<!-- END: FORM -->
					</div>
				</div>
			</div>
      	</div>
    </div>
</section>
@stop