67 lines
2.9 KiB
Twig
67 lines
2.9 KiB
Twig
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{% extends 'base.html.twig' %}
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{% block title %}Add Referral Source
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{% endblock %}
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{% block body %}
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{{ block('nav', 'internal/libs/nav.html.twig') }}
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<main class="main-content position-relative max-height-vh-100 h-100 border-radius-lg ">
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{{ block('topnav', 'internal/libs/top-nav.html.twig') }}
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<section>
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<div class='page-header min-vh-100'>
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<div class='container'>
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<div class="row">
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<div class="col-6 d-lg-flex d-none h-100 my-auto pe-0 position-absolute top-0 start-0 text-center justify-content-center flex-column">
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<div class="position-relative bg-gradient-primary h-100 m-3 px-7 border-radius-lg d-flex flex-column justify-content-center" style="background-image: url('/assets/img/illustrations/illustration-signup.jpg'); background-size: cover;"></div>
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</div>
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<div class="col-xl-4 col-lg-5 col-md-7 d-flex flex-column ms-auto me-auto ms-lg-auto me-lg-5">
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<div class="card card-plain">
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<div class="card-header">
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<h4 class="font-weight-bolder">Add Referral Source</h4>
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<p class="mb-0">Add a source of receiving referrals</p>
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</div>
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<div class="card-body">
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{{ form_errors(form) }}
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{{ form_start(form) }}
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<div class='input-group input-group-outline mb-3'>
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<label for='ref_src_name' class='form-label'>Name</label>
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<input type='text' name='{{ field_name(form.name) }}' id='ref_src_name' placeholder='' class='form-control' required='required'/>
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</div>
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<div class='input-group input-group-outline mb-3'>
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<label for='ref_src_agency' class='form-label'>Agency</label>
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<input type='text' name='{{ field_name(form.agency) }}' id='ref_src_agency' placeholder='' class='form-control' required='required'/>
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</div>
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<div class='input-group input-group-outline mb-3'>
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<label for='ref_src_email' class='form-label'>Email</label>
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<input type='email' name='{{ field_name(form.email) }}' id='ref_src_email' placeholder='' class='form-control' required='required'/>
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</div>
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<div class='input-group input-group-outline mb-3'>
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<label for='ref_src_phone' class='form-label'>Phone</label>
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<input type='phone' name='{{ field_name(form.phone) }}' id='ref_src_phone' placeholder='' class='form-control'/>
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</div>
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<div class='input-group input-group-outline mb-3'>
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<label for='ref_src_county' class='form-label'>County</label>
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<input type='text' name='{{ field_name(form.county) }}' id='ref_src_county' placeholder='' class='form-control'/>
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</div>
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<div class='text-center'>
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<button type='submit' class='btn btn-lg bg-gradient-dark btn-lg w-100 mt-4 mb-0'>Add Source</button>
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</div>
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{{ form_end(form) }}
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</div>
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</div>
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</div>
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</div>
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</div>
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</section>
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</main>
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{% endblock %}
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