<div class="border rounded-3 px-lg-4 px-md-2 px-3 pb-3 form" id="second-opinion-section">
    <h2 class="f-20 f-sm-20 mb-1 mt-2 clrBlueDark fw-500">Need a second opinion?</h2>
    <p class="f-14  fw-500 f-sm-14 clr5c  mb-3">
        Get reliable medical advice anytime, anywhere.
    </p>
    <form class="align-items-center labelled-form justify-content-center mb-md-0 mb-0 mt-md-0" id="secondOpinionForm" method="POST" enctype="multipart/form-data">
        @csrf
        {!! RecaptchaV3::field('secondOpinion') !!}
        <div class="col-md-12">
            <div class="form-group mb-3 mb-md-3">
                <label>Name</label>
                <input type="text"
                    class="form-control inputBox"
                    name="name"
                    onkeydown="return /[a-z, ]/i.test(event.key)"
                    onblur="if (this.value == '') {this.value = '';}"
                    onfocus="if (this.value == '') {this.value='';}"
                >
                <span class="errorMsg"></span>
            </div>
        </div>
        <div class="col-md-12">
            <div class="form-group mb-3 mb-md-3">
                <label>Mobile</label>
                <input type="text"
                    class="form-control inputBox"
                    name="phone"
                    minlength="5"
                    maxlength="10"
                    pattern="[0-9]{10}"
                >
            </div>
        </div>

        <div class="col-md-12">
            <div class="form-group mb-3 mb-md-3">
                <label>Email ID</label>
                <input type="text" class="form-control inputBox" name="email">
            </div>
        </div>

        <input type="hidden" class="form-control" name="source_url" value="{{ request()->fullUrl() }}">
        <input type="hidden" class="form-control" name="speciality" value="{{ $speciality->SpecialityName }}">

        {{-- <div class="col-md-12">
            <div class="form-group mb-3 mb-md-3">
                <label>Speciality</label>
                <select name="speciality" class="form-control form-select inputBox">
                    <option value="">Choose Speciality</option>
                    @foreach($secondOpinionSpecialities as $secondOpinionSpeciality)
                        <option value="{{ $secondOpinionSpeciality->SpecialityName }}">{{ $secondOpinionSpeciality->SpecialityName }}</option>
                    @endforeach
                    <option value="Kidney Transplant">Kidney Transplant</option>
                    <option value="Uro Surgery/Laser Uro Surgery">Uro Surgery/Laser Uro Surgery</option>
                    <option value="Cochlear Implant Surgery">Cochlear Implant Surgery</option>
                    <option value="LASIK Surgery">LASIK Surgery</option>
                    <option value="Cataracts">Cataracts</option>
                    <option value="Other">Other</option>
                </select>
            </div>
        </div> --}}

        <div class="col-md-12">
            <div class="form-group mb-3 mb-md-3">
                <div class="custom-file-btn position-relative upload-file-new">
                    <i class="fa-solid fa-cloud-arrow-up me-2"></i>
                    <label> Upload Prescription</label>
                    <input type="file" class="hide_file" name="file_attachment" id="secondOpinionFileAttachment">
                </div>
            </div>
        </div>

        <div class="col-md-12">
            <div class="form-group mb-3 mb-md-3">
                <label>Query</label>
                <textarea class="form-control" rows="2" name="remark"></textarea>
            </div>
        </div>
        <input type="hidden" name="subject_line" value="Second Opinion Form">
        <div class="col-md-12 terms-condition-error">
            <div class="form-check ">
                <input class="form-check-input inputBox" type="checkbox" id="tc" name="tc" checked>
                <label class="form-check-label f-13 text-black" for="tc">I agree to the <a href="{{ url('terms-and-conditions') }}" class="no-underline clrBlueDark">terms and conditions</a></label>
            </div>
            <div class="col-md-12 mb-2 mt-2 pt-2 mb-md-0">
                <button type="submit" class="btn text-white f-18 f-sm-18 fw-500 bgBlueDark rounded-3 w-100 btn-block secondOpinionBtn">
                    Submit
                </button>
            </div>
        </div>
    </form>
</div>

<div class="on-success bgBlueDark text-center text-white" style="display: none">
    <div class="border rounded-3 px-4 py-3 mt-3">
        <p>Your request has been submitted, our team will contact you soon.</p>
    </div>
</div>