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<?php $__env->startSection('title', 'Joruri Doctor | MPO Registration'); ?>

<?php $__env->startSection('content'); ?>
  <div class="main-content">
  <div class="main-content-inner">
      <div class="breadcrumbs ace-save-state" id="breadcrumbs">
         <?php echo $__env->make('layouts.header_menu', \Illuminate\Support\Arr::except(get_defined_vars(), ['__data', '__path']))->render(); ?>
      </div>
      <div class="page-content">
          <div class="row">
            <div class="col-xs-12">
              <div class="row">
                <div class="col-sm-3"></div>
                <div class="col-sm-6">
                  <div class="widget-box">
                    <div class="widget-header">
                      <h4 class="widget-title">MPO Registration</h4>
                      <div class="widget-toolbar">
                        <a href="#" data-action="collapse">
                          <i class="ace-icon fa fa-chevron-up"></i>
                        </a>

<a href="#" data-action="close">
                          <i class="ace-icon fa fa-times"></i>
                        </a>
                      </div>
                    </div>
                    <div class="widget-body">
                        <?php if($errors->any()): ?>
                          <div class="alert alert-danger">
                              <ul>
                                  <?php $__currentLoopData = $errors->all(); $__env->addLoop($__currentLoopData); foreach($__currentLoopData as $error): $__env->incrementLoopIndices(); $loop = $__env->getLastLoop(); ?>
                                      <li><?php echo e($error); ?></li>
                                  <?php endforeach; $__env->popLoop(); $loop = $__env->getLastLoop(); ?>
                              </ul>
                          </div>
                        <?php endif; ?>
                      <div class="widget-main">
                        <form action="<?php echo e(route('store_mpos')); ?>" method="post">
                          <?php echo csrf_field(); ?>

<div class="form-group">
                            <input class="form-control" type="text" name="customer_name" placeholder="MPO Name">
                            <?php $__errorArgs = ['customer_name'];
$__bag = $errors->getBag($__errorArgs[1] ?? 'default');
if ($__bag->has($__errorArgs[0])) :
if (isset($message)) { $__messageOriginal = $message; }
$message = $__bag->first($__errorArgs[0]); ?>
                              <span class="invalid-feedback" role="alert">
                                  <strong style="color: red;"><?php echo e($message); ?></strong>
                              </span>
                            <?php unset($message);
if (isset($__messageOriginal)) { $message = $__messageOriginal; }
endif;
unset($__errorArgs, $__bag); ?>
                          </div>

<div class="form-group">
                            <input class="form-control" type="number" name="customer_mobile" placeholder="MPO Mobile">
                            <?php $__errorArgs = ['customer_mobile'];
$__bag = $errors->getBag($__errorArgs[1] ?? 'default');
if ($__bag->has($__errorArgs[0])) :
if (isset($message)) { $__messageOriginal = $message; }
$message = $__bag->first($__errorArgs[0]); ?>
                              <span class="invalid-feedback" role="alert">
                                  <strong style="color: red;"><?php echo e($message); ?></strong>
                              </span>
                            <?php unset($message);
if (isset($__messageOriginal)) { $message = $__messageOriginal; }
endif;
unset($__errorArgs, $__bag); ?>
                          </div>

<div class="form-group">
                            <input class="form-control" type="email" name="customer_email" placeholder="MPO Email">
                            <?php $__errorArgs = ['customer_email'];
$__bag = $errors->getBag($__errorArgs[1] ?? 'default');
if ($__bag->has($__errorArgs[0])) :
if (isset($message)) { $__messageOriginal = $message; }
$message = $__bag->first($__errorArgs[0]); ?>
                              <span class="invalid-feedback" role="alert">
                                  <strong style="color: red;"><?php echo e($message); ?></strong>
                              </span>
                            <?php unset($message);
if (isset($__messageOriginal)) { $message = $__messageOriginal; }
endif;
unset($__errorArgs, $__bag); ?>
                          </div>
                          
                          <div class="form-group">
                            <input class="form-control" type="password" name="password" placeholder="Password">
                            <?php $__errorArgs = ['password'];
$__bag = $errors->getBag($__errorArgs[1] ?? 'default');
if ($__bag->has($__errorArgs[0])) :
if (isset($message)) { $__messageOriginal = $message; }
$message = $__bag->first($__errorArgs[0]); ?>
                              <span class="invalid-feedback" role="alert">
                                  <strong style="color: red;"><?php echo e($message); ?></strong>
                              </span>
                            <?php unset($message);
if (isset($__messageOriginal)) { $message = $__messageOriginal; }
endif;
unset($__errorArgs, $__bag); ?>
                          </div>

<div class="form-group">
                            <input class="form-control" type="password" name="password_confirmation" placeholder="Confirm Password">
                            <?php $__errorArgs = ['password_confirmation'];
$__bag = $errors->getBag($__errorArgs[1] ?? 'default');
if ($__bag->has($__errorArgs[0])) :
if (isset($message)) { $__messageOriginal = $message; }
$message = $__bag->first($__errorArgs[0]); ?>
                              <span class="invalid-feedback" role="alert">
                                  <strong style="color: red;"><?php echo e($message); ?></strong>
                              </span>
                            <?php unset($message);
if (isset($__messageOriginal)) { $message = $__messageOriginal; }
endif;
unset($__errorArgs, $__bag); ?>
                          </div>

<div class="form-group">
                            <select class="chosen-select form-control" name="customer_company" data-placeholder="Company Name">
                              <option>Service Company</option>
                              <?php $__currentLoopData = $company; $__env->addLoop($__currentLoopData); foreach($__currentLoopData as $company): $__env->incrementLoopIndices(); $loop = $__env->getLastLoop(); ?>
                                <option value="<?php echo e($company->company_name); ?>"><?php echo e($company->company_name); ?></option>
                              <?php endforeach; $__env->popLoop(); $loop = $__env->getLastLoop(); ?>
                            </select>
                            <?php $__errorArgs = ['mpo_company'];
$__bag = $errors->getBag($__errorArgs[1] ?? 'default');
if ($__bag->has($__errorArgs[0])) :
if (isset($message)) { $__messageOriginal = $message; }
$message = $__bag->first($__errorArgs[0]); ?>
                              <span class="invalid-feedback" role="alert">
                                  <strong style="color: red;"><?php echo e($message); ?></strong>
                              </span>
                            <?php unset($message);
if (isset($__messageOriginal)) { $message = $__messageOriginal; }
endif;
unset($__errorArgs, $__bag); ?>
                          </div>
                            
                          <div class="form-group">
                            <select class="chosen-select form-control" data-placeholder="Service Area..." name="chamber_area" autocomplete="off">
                                <option>Service Area</option>
                            <?php $__currentLoopData = $upazilas; $__env->addLoop($__currentLoopData); foreach($__currentLoopData as $upazilas): $__env->incrementLoopIndices(); $loop = $__env->getLastLoop(); ?>
                              <option value="<?php echo e($upazilas->id); ?>"><?php echo e($upazilas->name); ?> -- <?php echo e($upazilas->url); ?></option>
                            <?php endforeach; $__env->popLoop(); $loop = $__env->getLastLoop(); ?>
                            </select>
                          </div>
                          
                          <div class="form-group">
                            <input type="text" name="end_date" id="c_date" class="form-control hidden" value="<?php $data = 10; echo date('Y-m-d', strtotime('+'.$data. 'day')) ?>">
                          </div>
                          
                          <div class="space-8"></div>
                          <div class="form-action center">
                            <button class="btn btn-warning btn-round" type="submit">MPO Registration</button>
                          </div>
                          
                        </form>
                      </div>
                    </div>
                  </div>
                </div>
              <div class="col-sm-3"></div>
            </div>
<?php $__env->stopSection(); ?>
<?php echo $__env->make('layouts.app', \Illuminate\Support\Arr::except(get_defined_vars(), ['__data', '__path']))->render(); ?><?php /**PATH /home/rejoandoctor/public_html/resources/views/Prescribe/doctor/mpo_registration_by_doctor.blade.php ENDPATH**/ ?>