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",e.jsx("span",{className:"text-red-500",children:"*"})]}),e.jsx("input",{type:"text",value:s.city,onChange:a=>i("city",a.target.value),className:l,placeholder:"City"}),e.jsx(n,{message:r.city})]}),e.jsxs("div",{children:[e.jsxs("label",{className:"block font-semibold text-gray-700 mb-2",children:["State"," ",e.jsx("span",{className:"text-red-500",children:"*"})]}),e.jsxs("select",{value:s.state,onChange:a=>i("state",a.target.value),className:`${l} bg-white`,children:[e.jsx("option",{value:"",children:"Select state..."}),Z.map(a=>e.jsx("option",{value:a,children:a},a)),s.state&&!Z.includes(s.state)&&e.jsx("option",{value:s.state,children:s.state})]}),e.jsx(n,{message:r.state})]})]})]})]}),e.jsxs("div",{className:"bg-white rounded-xl shadow-sm border border-gray-200 p-6 sm:p-8",children:[e.jsx(L,{index:"3",title:"Personal Details",icon:Ne}),e.jsxs("div",{className:"grid grid-cols-1 sm:grid-cols-2 gap-5",children:[e.jsxs("div",{children:[e.jsxs("label",{className:"block font-semibold text-gray-700 mb-2",children:["Date of Birth"," ",e.jsx("span",{className:"text-red-500",children:"*"})]}),e.jsx(ee,{value:s.date_of_birth,onChange:a=>i("date_of_birth",a),max:new Date().toISOString().slice(0,10)}),e.jsx(n,{message:r.date_of_birth})]}),e.jsxs("div",{children:[e.jsx("label",{className:"block font-semibold text-gray-700 mb-2",children:"Date of Anniversary"}),e.jsx(ee,{value:s.date_of_anniversary,onChange:a=>i("date_of_anniversary",a),max:new Date().toISOString().slice(0,10)}),e.jsx("p",{className:"text-sm text-gray-500 mt-1",children:"Please enter your wedding anniversary date, if you wish to
1share it."}),e.jsx(n,{message:r.date_of_anniversary})]})]})]}),e.jsxs("div",{className:"bg-white rounded-xl shadow-sm border border-gray-200 p-6 sm:p-8",children:[e.jsx(L,{index:"4",title:"Social Media & Professional Profiles",subtitle:"Please provide the links to your social media/professional profiles, if available. These fields are optional.",icon:ve}),e.jsx("div",{className:"space-y-5",children:[{key:"instagram_url",label:"Instagram Profile URL",placeholder:"https://instagram.com/yourprofile"},{key:"facebook_url",label:"Facebook Profile/Page URL",placeholder:"https://facebook.com/yourpage"},{key:"twitter_url",label:"Twitter / X Profile URL",placeholder:"https://x.com/yourprofile"},{key:"linkedin_url",label:"LinkedIn Profile URL",placeholder:"https://linkedin.com/in/yourprofile"},{key:"youtube_url",label:"YouTube Channel URL",placeholder:"https://youtube.com/@yourchannel"}].map(a=>e.jsxs("div",{children:[e.jsx("label",{className:"block font-semibold text-gray-700 mb-2",children:a.label}),e.jsx("input",{type:"url",value:s[a.key],onChange:t=>i(a.key,t.target.value),className:l,placeholder:a.placeholder}),e.jsx(n,{message:r[a.key]})]},a.key))}),e.jsxs("div",{className:"mt-7 space-y-4 border-t border-gray-200 pt-6",children:[e.jsxs("label",{className:"flex gap-3 cursor-pointer",children:[e.jsx("input",{type:"checkbox",checked:s.consent_data_bank,onChange:a=>i("consent_data_bank",a.target.checked),className:"mt-1 w-4 h-4 rounded border-gray-400 text-primary focus:ring-primary shrink-0"}),e.jsxs("span",{className:"text-sm text-gray-700 leading-relaxed",children:["I confirm that the information provided by me is accurate and may be used by HSL Homoeopathy for maintaining and validating its professional Doctor Data Bank and for relevant professional communication and appreciation initiatives."," ",e.jsx("span",{className:"text-red-500",children:"*"})]})]}),e.jsx(n,{message:r.consent_data_bank}),e.jsxs("label",{className:"flex gap-3 cursor-pointer",children:[e.jsx("input",{type:"checkbox",checked:s.consent_communications,id:"consent_communications",required:!0,"aria-invalid":!!r.consent_communications,onChange:a=>{i("consent_communications",a.target.checked),_("consent_communications")},className:"mt-1 w-4 h-4 rounded border-gray-400 text-primary focus:ring-primary shrink-0"}),e.jsxs("span",{className:"text-sm text-gray-700 leading-relaxed",children:["I would like to receive relevant professional updates, initiatives and communications from HSL Homoeopathy."," ",e.jsx("span",{className:"text-red-500",children:"*"})]})]}),e.jsx(n,{message:r.consent_communications})]})]}),e.jsxs("div",{className:"bg-white rounded-xl shadow-sm border border-gray-200 p-6 sm:p-8",children:[!g&&e.jsxs("div",{className:"mb-4 flex items-start gap-2 text-sm text-amber-800 bg-amber-50 border border-amber-200 rounded-lg px-4 py-3",children:[e.jsx(ke,{className:"w-4 h-4 mt-0.5 shrink-0"}),e.jsx("span",{children:"Please verify your email address with the OTP above before submitting this form."})]}),e.jsx("button",{type:"submit",disabled:h||!g,className:"w-full sm:w-auto px-8 py-3 rounded-lg bg-primary text-white font-bold text-base hover:bg-primary/90 disabled:opacity-60 disabled:cursor-not-allowed transition",children:h?e.jsxs("span",{className:"flex items-center justify-center gap-2",children:[e.jsx(w,{className:"w-4 h-4 animate-spin"}),"Submitting..."]}):"Submit Form"})]})]})]})]})]})}export{Qe as default};
Line numbers count LF bytes from the start of the resource, as the search results do. Vendor segments are library code the classifier recognised; they are stored but not indexed. Bytes are shown as Latin1 characters, one per byte.