@extends('frontend.layouts.amp') @section('title', $data['page']->meta_title) @section('meta_keywords', $data['page']->meta_keywords) @section('meta_description', $data['page']->meta_description) @section('content')

{{ $data['page']->heading }}

{!! $data['page']->content !!} @include('includes.partials.messages') {!! Form::open(array('method' => 'POST', 'id' => 'frm_request_session')) !!}
{!! Form::label('email', 'Email Address:') !!} * {!! Form::text('email', null, ['type' => 'email', 'required' => 'required', 'class' => 'form-control1', 'placeholder' => 'Enter email address ...', 'id' => 'sp_email']) !!}
{!! Form::label('first_name', 'First Name:') !!} * {!! Form::text('first_name', null,['class'=>'form-control1', 'required' => 'required', 'placeholder'=>'Enter first name ...']) !!}
{!! Form::label('last_name', 'Last Name:') !!} * {!! Form::text('last_name', null,['class'=>'form-control1', 'required' => 'required', 'placeholder'=>'Enter last name ...']) !!}
{!! Form::label('company', 'Company:') !!} {!! Form::text('company', null,['class'=>'form-control1', 'placeholder'=>'Enter company name ...']) !!}
{!! Form::label('phone', 'Phone:') !!} * {!! Form::text('phone', null,['class'=>'form-control1', 'required' => 'required', 'placeholder'=>'Enter phone ...']) !!}
{!! Form::label('city', 'City:') !!} {!! Form::text('city', null,['class'=>'form-control1', 'placeholder'=>'Enter city ...']) !!}
{!! Form::label('zip', 'Zip / Post Code:') !!} {!! Form::text('zip', null,['class'=>'form-control1', 'placeholder'=>'Enter zip / post code ...']) !!}
{!! Form::label('product', 'Product You Are Interested In:') !!} {!! Form::text('product', null,['class'=>'form-control1', 'placeholder'=>'Product You Are Interested In ...']) !!}
{!! 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-control1 w-90', 'required' => 'required', 'placeholder'=>'Please Select ...']) !!}
{!! Form::label('time_to_call', 'Best Time to Call You:') !!} * {!! Form::select('time_to_call', ['Morning' => 'Morning', 'Afternoon' => 'Afternoon', 'Evening' => 'Evening'] ,null ,['class'=>'form-control1 w-90', 'required' => 'required', 'placeholder'=>'Please Select ...']) !!}
{!! Form::label('comments', 'Additional Comments:') !!} {!! Form::textarea('comments', null,['class'=>'form-control1', 'placeholder'=>'Additional Comments ...']) !!}
{!! Form::close() !!}
@endsection