@extends('frontend.layouts.landing') @section('title', 'Enter to Win - ' . app_name()) @push('head-area') @endpush @section('content')
{{--
AAEP Show Special
--}}
{{ app_name() }}
Sign up! To get free access to webinars hosted by Dr.Jan Bellows DAVDC, DABVP
Doctor Bellows has earned various distinctions throughout his career, including the Gold Star Award from the Florida Veterinary Medical Association and the Peter Emily Service Award. He has also authored five veterinary dentistry textbooks and facilitated the creation of all three versions of the American Animal Hospital Dental Guidelines.
He brings a wealth of knowledge and experience that will benefit veterinarians and their patients. He practiced for over twenty years in Pembroke Pines before establishing Hometown Animal Hospital and Dental Clinic in February 2000 in Weston, Florida.
REGISTER FOR WEBINARS
@include('includes.partials.messages') {!! Form::open(array('method' => 'POST', 'id' => 'frm_enter_to_win')) !!}
{!! Form::label('email', 'Email Address:') !!} * {!! Form::text('email', null, ['type' => 'email', 'required' => 'required', 'class' => 'form-control', 'placeholder' => 'Enter email address ...', 'id' => 'sp_email']) !!}
{!! Form::label('first_name', 'First Name:') !!} * {!! Form::text('first_name', null,['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Enter first name ...']) !!}
{!! Form::label('last_name', 'Last Name:') !!} * {!! Form::text('last_name', null,['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Enter last name ...']) !!}
{!! Form::label('company', 'Company/Institute:') !!} * {!! Form::text('company', null,['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Enter company/institute name ...']) !!}
{!! Form::label('phone', 'Phone:') !!} * {!! Form::text('phone', null,['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Enter phone ...']) !!}
{!! Form::label('address', 'Address:') !!} * {!! Form::text('address', null,['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Enter address ...']) !!}
{!! Form::label('city', 'City:') !!} * {!! Form::text('city', null,['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Enter city ...']) !!}
{!! Form::label('state', 'State:') !!} * {!! Form::select('state', $data['states'] ,null ,['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Please Select ...']) !!}
{!! Form::label('zip', 'Zip / Post Code:') !!} * {!! Form::text('zip', null,['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Enter zip / post code ...']) !!}
{!! Form::label('role', 'Your Role:') !!} * {!! Form::select('role', ['Veterinarian' => 'Veterinarian', 'Dentist' => 'Dentist', 'Technician' => 'Technician', 'Office Manager' => 'Office Manager', 'Clinic Owner' => 'Clinic Owner', 'Associated with Hospital' => 'Associated with Hospital', 'Other' => 'Other'] ,null ,['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Please Select ...']) !!}
{!! Form::label('role', 'Your Speciality:') !!} * {!! Form::select('speciality', ['Dental' => 'Dental', 'Orthopedic' => 'Orthopedic', 'Soft Tissue' => 'Soft Tissue', 'Spay Neuter' => 'Spay Neuter'] ,null ,['id' => 'newsletter-speciality', 'class'=>'form-control', 'required' => 'required', 'placeholder' => 'Your speciality ...']) !!}
{!! Form::label('comments', 'Additional Comments:') !!} {!! Form::textarea('comments', null,['class'=>'form-control', 'placeholder'=>'Additional Comments ...', 'rows' => '3']) !!}
Please fill complete details in order to make yourself eligible for free webinars.
{!! Form::close() !!}
@push('after-scripts') @endpush @endsection