<extend name="Public/base"/>
<block name="body">
<script src="__JS__/layer/layer.js" type="text/javascript"></script>
<script src="__JS__/xiaobing.js" type="text/javascript"></script>
<div id="page_block3" style="clear:both;">
    <div class="sp_area_1">
        <!-- banner -->
        <include file="Public/top_banner" />
    </div>
    <div class="sp_area_1">
        <div class="box">
            <h3>
               {$category.title}
            </h3>
            <div class="text">
               <div class="page_order">
                    <div class="panel-heading">
                        <p><strong>井手歯科クリニック (桜新町駅 | 世田谷区)</strong></p>
                         <p class="text-red">こちらは初診専用の予約電話・予約システムです。再診の患者様は、医院の番号に直接ご連絡ください。</p>
                    </div>
                    <div class="panel-body">
                        <!-- form -->
                        <div class="form-panel"  >
                        <form class="form-horizontal ajax-post" id="formlist" action="{:U('Messages/add')}" method="post">
                            <div class="row">

                              <div class="form-group clearfix">
                                <div class="col-xs-3">
                                    <label for="#" class="fl">姓名</label>
                                    <span class="need fr">必填</span>
                                </div>
                                <div class="col-xs-9">
                                     <input type="text" class="form-control" id="exampleInputAddress1" placeholder="请输入您的姓名" name="name" data-validate="required:姓名不能为空">
                                </div>
                              </div>
                              <div class="form-group clearfix">
                                <div class="col-xs-3">
                                    <label for="#" class="fl">电话</label>
                                    <span class="need fr">必填</span>
                                </div>
                                <div class="col-xs-9">
                                     <input type="text" class="form-control" id="exampleInputAddress2" placeholder="请输入您的电话号码" name="phone" data-validate="required:电话不能为空,tel:电话格式错误">
                                </div>
                              </div>
                              <div class="form-group clearfix">
                                <div class="col-xs-3" style="padding:60px 20px">
                                    <label for="#" class="fl">留言咨询</label>
                                    <span class="need fr">必填</span>
                                </div>
                                <div class="col-xs-9">
                                     <textarea class="form-control text" placeholder="您可以在这里输入您的问题" name="content" data-validate="required:留言内容不能为空"></textarea>
                                </div>
                              </div>
                              <div class="form-group clearfix">
                                <div class="col-xs-3">
                                    <label for="#" class="fl">验证码</label>
                                    <span class="need fr">必填</span>
                                </div>
                                <div class="col-xs-9">
                                    <input type="text" name="verify"  class="form-control vcode fl" id="" placeholder="请输入右侧验证码">
                                    <img src="{:U('Messages/verify')}"  class="vcodeImg fl" id="de" onclick="reloadcode()">
                                </div>
                              </div>


                            </div>

                            <div class="col-xs-12" style="text-align:center;margin-top:20px">
                                  <button type="submit" id="submitTiJiao" class="btn btn-submit">立即在线预约</button>
                            </div>
                           </form>
                        </div>
                    </div>
                    <div class="panel-foot">
                        <p>您也可以选择直接与我们取得联系，请拨打以下电话</p>
                        <p style="font-size:24px;color:#f4901e"><b>028-8888-8888</b></p>
                    </div>
                    
                </div>


            </div>
        </div>
    </div>
</div>  
<script>
$(function(){
$('#submit').xbValidform();
});
</script>
<script type="text/javascript">
function reloadcode(){
var verify=document.getElementById('de');
verify.setAttribute('src','{:U('Messages/verify')}?'+Math.random());
}
</script>  
</block>          