@extends('Layouts/simplified') @section('content') {!! Form::open(['data-toggle' => 'validator']) !!} @if (isset($product))

Selected product

{{ $product->name }}
1 × @if ($product->price) {{ $currency->symbol}}{{ $product->price }} @else free @endif
@endif

Customer details

{!! Form::label('data[User][first_name]', t('First Name')) !!} {!! Form::text( 'data[User][first_name]', (isset($data->first_name) ? $data->first_name : null), [ 'placeholder' => t('First Name'), 'data-error' => t('This field is required'), 'class' => 'form-control input-huge input-cusive', 'required' ] ) !!}
@if (isset($errors->first_name)) {{ $errors->first_name[0] }} @endif
{!! Form::label('data[User][last_name]', t('Last Name')) !!} {!! Form::text( 'data[User][last_name]', (isset($data->last_name) ? $data->last_name : null), [ 'placeholder' => t('Last Name'), 'data-error' => t('This field is required'), 'class' => 'form-control input-huge input-cusive', 'required' ] ) !!}
@if (isset($errors->last_name)) {{ $errors->last_name[0] }} @endif
{!! Form::label('data[User][email]', t('Email')) !!} {!! Form::email( 'data[User][email]', (isset($data->email) ? $data->email : null), [ 'placeholder' => t('Email'), 'data-error' => t('This field is required and need to be valid email'), 'class' => 'form-control input-huge input-cusive', 'required' ] ) !!}
@if (isset($errors->email)) {{ $errors->email[0] }} @endif
{!! Form::label('data[User][phone]', t('Phone')) !!} {!! Form::text( 'data[User][phone]', (isset($data->phone) ? $data->phone : null), [ 'placeholder' => t('Phone'), 'data-error' => t('Please add valid mobile phone number'), 'class' => 'form-control input-huge input-cusive', 'pattern' => '^(\+|0)[0-9]{10,15}$' ] ) !!}
@if (isset($errors->phone)) {{ $errors->phone[0] }} @endif
@if (isset($product_id) && $product_id)
{!! Form::label('data[User][birthday]', t('Date of Birth')) !!} {!! Form::text( 'data[User][birthday]', (isset($data->birthday) ? $data->birthday : null), [ 'class' => 'form-control birthdaypicker select-huge' ] ) !!}
@endif @include('Elements/User/toc_promotions', ['data' => []]) {!! Form::submit( t('Submit'), ['class' => 'btn btn-huge btn-pink btn-block'] ) !!} {!! Form::close() !!} {{--

This is to comply with Goverment Track & Trace and will be held for 21 days after your visit




Start over
--}}


@endsection