ikan Uploader :
Directory : /var/www/html/shardahospital.org/application/views/
Upload File : |
| Current File : /var/www/html/shardahospital.org/application/views/feedback.php |
<div class="sliderinners">
<div class="container">
<div class="row">
<div class="col-md-12">
<h2>Share your Feedback </h2>
</div>
</div>
</div>
</div>
<div class="appoinform">
<div class="container">
<div class="row">
<div class="col-md-2"></div>
<div class="col-md-8">
<form action="<?php echo base_url('feedback/formsubmit');?>" method="post" enctype="multipart/form-data">
<div class="row">
<?php if ($this->session->flashdata('submit_status_msg')) { ?>
<p style="font-size:18px;"><?php echo $this->session->flashdata('submit_status_msg'); ?></p>
<?php } ?>
<div class="col-md-12">
<div class="form-app" id="myRadio">
<span>Type of Query</span>
<label><input type="radio" name="radio" value="Feedback" checked> Feedback </label>
<label><input type="radio" name="radio" value="Suggestion"> Suggestion </label>
<label><input type="radio" name="radio" value="Complaint"> Complaint </label>
</div>
</div>
<div class="col-md-6">
<div class="form-app">
<span>Name</span>
<input type="text" autocomplete=OFF value="" name="name" id="name" class=""
maxlength="150" required />
<small id="namevalid" class="form-text text-muted invalid-feedback">
Your username must be more than 2 characters long and should start with a Capital
letter.
</small>
</div>
</div>
<div class="col-md-6">
<div class="form-app">
<span>Email</span>
<input type="text" maxlength="100" value="" name="email" class="" id="emailid"
autocomplete=OFF required />
<small id="emailvalid" class="form-text text-muted invalid-feedback">
Your email must be a valid email
</small>
</div>
</div>
<div class="col-md-6">
<div class="form-app">
<span>Phone No</span>
<input type="text" value="" onkeyup="this.value=this.value.replace(/[^\d]/,'')"
autocomplete="off" name="phone" id="contact_number" maxlength="10" required />
</div>
</div>
<div class="col-md-6">
<div class="form-app">
<span>Select Country</span>
<select id="country" name="country">
<option value="">Select</option>
</select>
</div>
</div>
<div class="col-md-6">
<div class="form-app">
<span>Select Speciality </span>
<select id="speciality" name="speciality" onchange="get_doctor()">
<option value="">Select</option>
<?php foreach($specialities as $val){ ?>
<option value="<?php echo $val['DepartmentID'];?>">
<?php echo $val['DepartmentName'];?>
</option>
<?php } ?>
</select>
</div>
</div>
<div class="col-md-6">
<div class="form-app">
<span>Select Doctor </span>
<select name="doctor" id="doctor">
</select>
</div>
</div>
<div class="col-md-12">
<div class="form-app">
<span>message </span>
<textarea name="message" maxlength="1500"></textarea>
</div>
</div>
<div class="col-md-12">
<script src="https://www.google.com/recaptcha/api.js" async defer></script>
<div class="g-recaptcha" data-sitekey="6LdytHImAAAAAHyFCAPeGPbanxU1K2rt84aF-9lL"></div>
</div>
<div class="col-md-12">
<div class="form-app">
<button type="submit" value="Submit" name="submit" id="submit" class="button5">Submit Request<span><i class="bi bi-arrow-right-short"></i></span></button>
</div>
</div>
</div>
</form>
</div>
</div>
</div>
</div>
<script src="https://ajax.googleapis.com/ajax/libs/jquery/3.7.0/jquery.min.js"></script>
<script>
$(document).on('click','#submit', function(){
var response = grecaptcha.getResponse();
if(response.length==0){
alert('Please verify you are not a robot');
return false;
}
});
</script>
<script>
function get_doctor() {
// var speciality = $('#speciality').val();
var speciality = document.getElementById('speciality').value;
$.ajax({
type: "POST",
url: "<?php echo base_url('feedback/ajaxgetdocrecord');?>",
data: { speciality },
cache: false,
dataType: 'json',
success: function (response) {
$('#doctor').html('');
$('#doctor').append($('<option>').text(' -- Select Doctor Name -- ').attr('value', ''));
$.each(response, function (value) {
$('#doctor').append($('<option>').text(value).attr('value', value));
});
},
error: function (error) {
console.log(error);
}
});
}
</script>
<script>
let noteCards = document.getElementById('country');
// console.log(noteCards.innerHTML);
fetch('https://countriesnow.space/api/v0.1/countries')
.then(response => response.json())
.then(data => {
for (let i = 0; i <= data.data.length; i++) {
let str = "";
// str +=`<option value='${data.data[i].country}'>${data.data[i].country}</option>`;
noteCards.innerHTML += `<option value='${data.data[i].country}'>${data.data[i].country}</option>`;
}
})
.catch(error => console.error(error))
</script>
<script>
const name = document.getElementById('name');
const email = document.getElementById('emailid');
const namevalid = document.getElementById("namevalid").style.display = "none";
const emailvalid = document.getElementById("emailvalid").style.display = "none";
// console.log(name);
// console.log(email);
name.addEventListener('blur', () => {
// console.log("name is blurred");
// Validate name here
let regex = /^[A-Z]([0-9a-zA-Z\s]){2,50}$/;
let str = name.value;
// console.log(regex, str);
if (regex.test(str)) {
// console.log('Your name is valid');
name.classList.remove('is-invalid');
const namevalid = document.getElementById("namevalid").style.display = "none";
}
else {
// console.log('Your name is not valid');
name.classList.add('is-invalid');
const namevalid = document.getElementById("namevalid").style.display = "block";
}
});
email.addEventListener('blur', () => {
console.log("email is blurred");
// Validate email here
let regex = /^([_\-\.0-9a-zA-Z]+)@([_\-\.0-9a-zA-Z]+)\.([a-zA-Z]){2,7}$/;
let str = email.value;
// console.log(regex, str);
if (regex.test(str)) {
// console.log('Your email is valid');
email.classList.remove('is-invalid');
const emailvalid = document.getElementById("emailvalid").style.display = "none";
}
else {
// console.log('Your email is not valid');
email.classList.add('is-invalid');
const emailvalid = document.getElementById("emailvalid").style.display = "block";
}
});
</script>
<script src="https://cdnjs.cloudflare.com/ajax/libs/jquery/3.5.1/jquery.min.js"
integrity="sha512-bLT0Qm9VnAYZDflyKcBaQ2gg0hSYNQrJ8RilYldYQ1FxQYoCLtUjuuRuZo+fjqhx/qtq/1itJ0C2ejDxltZVFg=="
crossorigin="anonymous"></script>
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