@extends('layout.master')
@section('content')
<main id="main">
   <!-- ======= Breadcrumbs ======= -->
   <div class="breadcrumbs">
      <div class="container">
         <div class="d-flex justify-content-between align-items-center">
            <ol>
               <li><a href="{{route('index')}}" class="text-white">Home</a></li>
               <li><a href="{{route('contact')}}" class="text-white">Pricing</a></li>
            </ol>
         </div>
      </div>
   </div>
   <!-- ======= Contact Section ======= -->
   <section id="contact" class="contact">
      <div class="container">
         <div class="section-title">
            <h1><strong class="heading-shadow">Fill In To Unlock Pricing Plans</strong></h1>
         </div>
      </div>
      <div class="container">
         @if ($errors->any())
             <div class="alert alert-danger">
                 <ul>
                     @foreach ($errors->all() as $error)
                         <li>{{ $error }}</li>
                     @endforeach
                 </ul>
             </div>
         @endif
         @if(isset($successMessage))
             <div class="alert alert-success" role="alert">
                 {{ $successMessage }}
             </div>
         @endif
         <div class="row">
            <div class="col-lg-12 mt-3">
               <form action="{{route('pricing.details')}}" method="post" role="form" class="php-email-form">
                  @csrf
                  <div class="row">
                     <div class="col-md-6 form-group">
                        <label for="profession" class="form-label">Select Profession<span class="text-red">*</span></label>
                        <select class="form-select" name="profession" id="profession" onautocomplete="field" required>
                           <option value="">I am a*</option>
                           <option value="Physician">Physician</option>
                           <option value="Healthcare Provider">Healthcare Provider</option>
                           <option value="Practice Staff">Practice Staff</option>
                           <option value="Laboratory">Laboratory</option>
                           <option value="Consultant">Consultant</option>
                           <option value="Hospital">Hospital</option>
                        </select>
                     </div>
                     <div class="col-md-6 form-group mt-3 mt-md-0">
                        <label for="company" class="form-label">Practice/Company Name<span class="text-red">*</span></label>
                        <input type="text" class="form-control" name="company" id="company" autocomplete="company"  placeholder="Practice or Company Name" required>
                     </div>

                     <div class="col-md-6 form-group  mt-3 mt-md-0">
                        <label for="full_name" class="form-label">Full Name<span class="text-red">*</span></label>
                        <input type="text" class="form-control" name="full_name" id="full_name" placeholder="Name" required>
                     </div>

                     <div class="col-md-6 form-group  mt-3 mt-md-0">
                        <label for="monthly_collection" class="form-label">Monthly Collection<span class="text-red">*</span></label>
                        <input type="number" min="0" class="form-control" name="monthly_collection" id="monthly_collection" autocomplete="monthly_collection" placeholder="Monthly Collection" required>
                     </div>
                     
                     <div class="col-md-6 form-group  mt-3 mt-md-0">
                        <label for="email" class="form-label">Email<span class="text-red">*</span></label>
                        <input type="email" class="form-control" name="email" id="email" autocomplete="email" placeholder="Email" required>
                     </div>
                     
                     <div class="col-md-6 form-group  mt-3 mt-md-0">
                        <label for="phone" class="form-label">Phone No.<span class="text-red">*</span></label>
                        <input type="number" min="0" maxlength="11" class="form-control" name="phone" id="phone" autocomplete="phone" placeholder="Phone Number" required>
                     </div>
                     
                     <div class="col-md-12 form-group  mt-3 mt-md-0">
                        <label for="message" class="form-label">Tell Us More About You</label>
                        <textarea class="form-control" name="message" id="message" rows="5" placeholder="Message" minlength="10"></textarea>
                     </div>
                  </div>
                  <br/>
                  <div class="text-center"><button type="submit" class="btn btn-primary">UNLOCK PRICING NOW</button></div>
            </div>
            
           
            </form>
         </div>
      </div>
      </div>
   </section>
   <!-- End Contact Section -->
</main>
<!-- End #main -->
@endsection