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  1. <div class="Myaccountleft">&nbsp;</div>
  2. <script type="text/javascript">
  3. function opentext(){
  4. if(document.getElementById('title').value=="Other"){
  5. document.getElementById('othertextbox').style.display="block";
  6. document.getElementById('othertitle').focus();
  7. }else{
  8. document.getElementById('othertextbox').style.display="none";
  9. }
  10. }
  11. </script>
  12. <form action="<?php echo $this->getUrl('askpharmacist/index/post'); ?>" id="askpharmacist" method="post">
  13. <div class="Rightpart">
  14. <div class="Border">
  15. <?php
  16. if(Mage::getSingleton('customer/session')->isLoggedIn())//if logged in
  17. {
  18. $customerAddressId = Mage::getSingleton('customer/session')->getCustomer()->getDefaultBilling();
  19. $address = Mage::getModel('customer/address')->load($customerAddressId)->getData();
  20.  
  21.  
  22. $customerPrefix = Mage::helper('customer')->getCustomer()->getData('prefix');
  23. $customer_f_Name = Mage::helper('customer')->getCustomer()->getData('firstname');
  24. $customer_email = Mage::helper('customer')->getCustomer()->getData('email');
  25. $customer_l_Name = Mage::helper('customer')->getCustomer()->getData('lastname');
  26. $customer_mphone = Mage::helper('customer')->getCustomer()->getData('mphone');
  27. $customer_buildingname = Mage::helper('customer')->getCustomer()->getData('buildingname');
  28. }
  29. ?>
  30. <?php echo $_SESSION['askpharmasuccess']; ?>
  31. <h1>Ask your Pharmacist</h1>
  32. <p class="PaddT8">If you would like to ask the SureCalm Pharmacist a question on your health or
  33. medication and receive a response via e-mail please complete the form below.</p>
  34. <p class="PaddT8">If you would prefer to talk to the Pharmacist please request a call back using the
  35. <a href="<?php echo $this->getUrl('callback');?>" class="private_tab">Request a Call Back</a> form or call the Pharmacy on freephone 0800 023 2558.</p>
  36. </div>
  37.  
  38. <div class="Personalinf">
  39.  
  40. <div class="floatR"><span class="Startcolor">*</span> Required Fields</div>
  41. <p class="personalinf">Personal information</p>
  42.  
  43. <div class="inputbox">
  44. <p class="textcolor">Title<span class="Startcolor">*</span></p>
  45. <p>
  46. <select class="selectbox required-entry" tabindex="1" name="title" id="title" onchange="javascript:opentext();">
  47. <option value="">select title</option>
  48. <option value="Mr" <?php if($customerPrefix=='Mr'){?> selected="selected" <?php } ?>>Mr</option>
  49. <option value="Miss" <?php if($customerPrefix=='Miss'){?> selected="selected" <?php } ?>>Miss</option>
  50. <option value="Ms" <?php if($customerPrefix=='Ms'){?> selected="selected" <?php } ?>>Ms</option>
  51. <option value="Mrs" <?php if($customerPrefix=='Mrs'){?> selected="selected" <?php } ?>>Mrs</option>
  52. <option value="Dr" <?php if($customerPrefix=='Dr'){?> selected="selected" <?php } ?>>Dr</option>
  53. <option value="Rev" <?php if($customerPrefix=='Rev'){?> selected="selected" <?php } ?>>Rev</option>
  54. <option value="Other" <?php if($customerPrefix=='Other'){?> selected="selected" <?php } ?>>Other</option>
  55. </select>
  56. </p>
  57. </div>
  58. <div class="inputbox1">
  59. <p class="textcolor">Email address<span class="Startcolor">*</span></p>
  60. <p>
  61. <input name="email" id="email" type="text" tabindex="4" value="<?php echo $customer_email ?>" class="inutetext required-entry" />
  62. </p>
  63. </div>
  64. <div class="inputbox">
  65. <p class="textcolor">First Name<span class="Startcolor">*</span></p>
  66. <p>
  67. <input name="name" id="name" tabindex="2" value="<?php echo $customer_f_Name ?>" type="text" class="inutetext required-entry" />
  68. </p>
  69. </div>
  70. <div class="inputbox1">
  71. <p class="textcolor">Re-type email address<span class="Startcolor">*</span></p>
  72. <p>
  73. <input name="cemail" id="cemail" type="text" tabindex="5" class="inutetext required-entry validate-cemail" />
  74. </p>
  75. </div>
  76. <div class="inputbox">
  77. <p class="textcolor">Surname<span class="Startcolor">*</span></p>
  78. <p>
  79. <input name="surname" tabindex="3" id="surname" value="<?php echo $customer_l_Name ?>" type="text" class="inutetext required-entry" />
  80. </p>
  81. </div>
  82.  
  83. </div>
  84. <!--personal info finish-->
  85. <!--Address info starts-->
  86. <div class="Personalinf">
  87.  
  88. <p class="personalinf">Address Information</p>
  89.  
  90. <div class="inputbox">
  91. <p class="textcolor">Telephone</p>
  92. <p><input type="text" name="telephone" tabindex="6" value="<?php echo $address['telephone'] ?>" class="inutetext" /></p>
  93. </div>
  94. <div id="othertextbox" style="display:none;">
  95. <p>Other Title<span class="Startcolor">*</span></p>
  96. <div class="floatR orange"></div>
  97. <p>
  98. <input name="othertitle" id="othertitle" tabindex="2" type="text" value="<?php echo $customerPrefix ?>" class="inutetext required-entry" />
  99. </p>
  100. </div>
  101.  
  102.  
  103.  
  104. <div class="inputbox1">
  105. <p class="textcolor"> Mobile Phone </p>
  106. <p>
  107. <input name="mphone" id="mphone" tabindex="10" value="<?php echo $customer_mphone ?>" type="text" class="inutetext" />
  108. </p>
  109. </div>
  110.  
  111.  
  112.  
  113.  
  114. <div class="inputbox">
  115. <p class="textcolor">Building name / number</p>
  116. <p>
  117. <input name="buildingname" id="buildingname" tabindex="7" value="<?php echo $customer_buildingname ?>" type="text" class="inutetext" />
  118. </p>
  119. </div>
  120.  
  121.  
  122.  
  123.  
  124. <div class="inputbox1">
  125. <p class="textcolor">Street</p>
  126. <p>
  127. <input name="street" id="street" tabindex="11" type="text" value="<?php echo $address['street'] ?>" class="inutetext" />
  128. </p>
  129. </div>
  130.  
  131.  
  132.  
  133.  
  134. <div class="inputbox">
  135. <p class="textcolor"> Town/City</p>
  136. <p><input name="city" id="city" tabindex="8" type="text" value="<?php echo $address['city'] ?>" class="inutetext" /></p>
  137. </div>
  138. <div class="inputbox1">
  139. <p class="textcolor">Postcode</p>
  140. <p>
  141. <input name="postcode" id="postcode" tabindex="12" type="text" value="<?php echo $address['postcode'] ?>" class="inutetext" /></p>
  142. </div>
  143. <div class="inputbox">
  144. <p class="textcolor">Country<span class="Startcolor">*</span></p>
  145. <p>
  146. <?php
  147. $defaultCountry = Mage::getStoreConfig('general/country/default');
  148. $_countries = Mage::getResourceModel('directory/country_collection')
  149. ->loadData()
  150. ->toOptionArray(false) ?>
  151.  
  152.  
  153. <?php if (count($_countries) > 0): ?>
  154. <select name="country" id="country" style="width:255px;" class="required-entry" tabindex="9">
  155. <option value="">-- Please Select --</option>
  156. <?php foreach($_countries as $_country): ?>
  157. <option value="<?php echo $_country['label'] ?>" <?php if($defaultCountry==$_country['value']) { ?> selected="selected" <?php }?> >
  158. <?php echo $_country['label'] ?>
  159. </option>
  160. <?php endforeach; ?>
  161. </select>
  162. <?php endif; ?>
  163. </p>
  164. </div>
  165.  
  166. <?php /*?> <div class="inputbox">
  167. <!--<p class="textcolor">If you do not have an e-mail address please use the
  168. <a href="<?php echo $this->getUrl('callback');?>" class="private_tab">Request a Call Back</a> form or call the Pharmacy on
  169. freephone 0800 023 2558</p>-->
  170.  
  171. </div><?php */?>
  172.  
  173.  
  174.  
  175. </div>
  176.  
  177.  
  178. <div class="Personalinf">
  179. <div class="inputbox">
  180. <p class="textcolor">Gender<span class="Startcolor">*</span></p>
  181. <p>
  182. <input type="radio" name="gender" tabindex="12" id="gender" value="Male" /> Male <input type="radio" tabindex="13" name="gender" id="gender" value="Female" /> Female
  183. </p>
  184. </div>
  185.  
  186.  
  187. <div class="inputbox1">
  188. <p class="textcolor">Age (years)<span class="Startcolor">*</span></p>
  189. <p>
  190. <input name="age" id="age" type="text" tabindex="14" class="inutetext022 required-entry" />
  191. </p>
  192. </div>
  193.  
  194. </div>
  195.  
  196.  
  197. <div class="Personalinf">
  198. <p class="personalinf">Your question</p>
  199.  
  200. <div class="inputbox">
  201. <p class="textcolor">Nature of Query<span class="Startcolor">*</span></p>
  202. <p>
  203. <select class="selectbox required-entry" tabindex="15" name="query" id="query">
  204. <option value="">Select One</option>
  205. <option value="Medicines Information">Medicines Information</option>
  206. <option value="NHS Prescription">NHS Prescription</option>
  207. <option value="Private Prescription">Private Prescription</option>
  208. <option value="Admin">Admin</option>
  209. <option value="Health/Illness">Health/Illness</option>
  210. <option value="Other">Other</option>
  211. </select>
  212. </p>
  213. </div>
  214. <div class="inputaera03">
  215. <p>Please give full details of the nature of your enquiry</p>
  216. <p>
  217. <textarea name="query_detail" tabindex="16" id="query_detail" class="inputaera_box03"></textarea>
  218. </p>
  219. </div>
  220.  
  221. </div>
  222. <div class="Personalinf">
  223. <p class="personalinf">Your medical status</p>
  224.  
  225. <div class="inputaera03">
  226. <p class="textcolor">Are you currently taking any medication?</p>
  227. <p>
  228. <input type="radio" name="medical_status" tabindex="17" id="medical_status" value="Yes" />
  229. Yes
  230. <input type="radio" name="medical_status" tabindex="18" id="medical_status" value="No" />
  231. No
  232.  
  233. </p>
  234. </div>
  235. <div class="inputaera03">
  236. <p>If Yes, please specify</p>
  237. <p><textarea name="medical_status_text" tabindex="19" id="medical_status_text" class="inputaera_box04"></textarea></p>
  238.  
  239. </div>
  240.  
  241. </div>
  242. <div class="Personalinf">
  243. <div class="inputaera03">
  244. <p class="textcolor">Have you contacted us about this before<span class="Startcolor">*</span></p>
  245. <p>
  246. <input type="radio" name="contactus_before" tabindex="20" class="validate-one-required-by-name" id="contactus_before" value="Yes" />
  247. Yes
  248. <input type="radio" name="contactus_before" tabindex="21" class="validate-one-required-by-name" id="contactus_before" value="No" />
  249. No
  250.  
  251. </p>
  252. </div>
  253.  
  254.  
  255. </div>
  256.  
  257. <div class="Personalinf1">
  258. <div class="inputbox"><p class="Fontsize"><input type="checkbox" tabindex="24" name="terms_condition" id="terms_condition" class="required-entry" />
  259. I accept the Terms and Conditions<span class="Startcolor">*</span></p>
  260. <p > <a href="<?php echo $this->getUrl('termandcondition');?>">Read our Terms and Conditions</a></p>
  261. </div>
  262. <div class="inputaera03">
  263. <p>Can we contact you with related information?<span class="Startcolor">*</span></p>
  264. <p><input type="radio" name="contact_confirmation" tabindex="22" class="validate-one-required-by-name" id="contact_confirmation" value="Yes" />
  265. Yes
  266. <input type="radio" name="contact_confirmation" tabindex="23" class="validate-one-required-by-name" id="contact_confirmation" value="No" />
  267. No
  268.  
  269. </p>
  270. </div>
  271. <div class="inputaera03">
  272. <!-- <button type="submit" title="<?php echo Mage::helper('contacts')->__('Submit') ?>" class="button"><span><span><?php echo Mage::helper('contacts')->__('Submit') ?></span></span></button>-->
  273. <div class="floatR">
  274.  
  275. <input type="reset" border="reset" value="Reset" class="Resetbutton" />
  276. <input type="submit" name="postbutton" tabindex="26" value="" class="regsub">
  277. <!--<a href="#"><img src="images/submit.jpg" border="0" /></a>--></div>
  278.  
  279.  
  280. </div>
  281.  
  282.  
  283. </div>
  284. </div>
  285. </form>
  286. <?php
  287. unset($_SESSION['askpharmasuccess']);
  288. ?>
  289. <script type="text/javascript">
  290. //<![CDATA[
  291. var contactForm = new VarienForm('askpharmacist', true);
  292. //]]>
  293. </script>
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