@extends('dashboard.layout.user')
@section('content')
<div class="container-fluid p-0">
    <div class="mainDashboard">
        <h2 class="mainHeading mb-1">Utilities - Collection Site Lookup</h2>
        <p>Search the list of available collection sites for substance abuse screening. This only includes direct CRA contracts with collection sites. It does not include collection site networks that are managed by third-party administrators (e.g. eScreen).</p>
        <div class="row">
            <div class="col-md-12">
                <div class="mainOrder mb-5">
                    <div class="billingform">
                        <form>
                            <div class="row">
                                <div class="col-md-12">
                                    <div class="form-group">
                                        <label for="">Collection Provider:</label>
                                        <select class="form-control">
                                            <option value="">None</option>
                                        </select>
                                    </div>
                                </div>
                                <div class="col-md-12">
                                    <div class="form-group">
                                        <label for="">Specimen Type:</label>
                                        <div class="check-wrap w-100">
                                            <label>
                                                <input type="checkbox">
                                                <span>Hair</span>
                                            </label>
                                            <label>
                                                <input type="checkbox">
                                                <span>Urine</span>
                                            </label>
                                            <label>
                                                <input type="checkbox">
                                                <span>Saliva</span>
                                            </label>
                                            <label>
                                                <input type="checkbox">
                                                <span>Blood</span>
                                            </label>
                                            <label>
                                                <input type="checkbox">
                                                <span>Breath Alcohol</span>
                                            </label>
                                        </div>
                                    </div>
                                </div>
                                <div class="col-md-6">
                                    <div class="form-group">
                                        <label for="">DOT Site:</label>
                                        <div class="check-wrap w-100">
                                            <label>
                                                <input type="checkbox">
                                                <span>DOT Collection Site Only</span>
                                            </label>
                                        </div>
                                    </div>
                                </div>
                                <div class="col-md-6">
                                    <div class="form-group">
                                        <label for="">Other Filters:</label>
                                        <div class="check-wrap w-100">
                                            <label>
                                                <input type="checkbox">
                                                <span>Instant POCT Sites Only</span>
                                            </label>
                                        </div>
                                    </div>
                                </div>
                                <div class="col-md-12">
                                    <div class="form-group ">
                                        <label for="">Quest Site Tier:</label>
                                        <div class="check-wrap w-100">
                                            <label>
                                                <input type="checkbox">
                                                <span>Patient Service Centers</span>
                                            </label>
                                            <label>
                                                <input type="checkbox">
                                                <span>Preferred</span>
                                            </label>
                                            <label>
                                                <input type="checkbox">
                                                <span>Third Party</span>
                                            </label>
                                        </div>
                                    </div>
                                </div>
                                <div class="col-md-3">
                                    <div class="form-group">
                                        <label for="">Address</label>
                                        <input class="form-control" placeholder="Address">
                                    </div>
                                </div>
                                <div class="col-md-3">
                                    <div class="form-group">
                                        <label for="">Zip</label>
                                        <input class="form-control" placeholder="zip">
                                    </div>
                                </div>
                                <div class="col-md-3">
                                    <div class="form-group">
                                        <label for="">City</label>
                                        <input class="form-control" placeholder="City">
                                    </div>
                                </div>
                                <div class="col-md-3">
                                    <div class="form-group">
                                        <label for="">State</label>
                                        <input class="form-control" placeholder="State">
                                    </div>
                                </div>
                                <div class="col-md-3">
                                    <div class="form-group">
                                        <label for="">Radius:</label>
                                        <select class="form-control">
                                            <option value="">10mi</option>
                                            <option value="">15mi</option>
                                            <option value="">20mi</option>
                                            <option value="">25mi</option>
                                            <option value="">30mi</option>
                                        </select>
                                    </div>
                                </div>
                                <div class="col-md-3">
                                    <div class="form-group">
                                        <label for="">Max Results</label>
                                        <select class="form-control">
                                            <option value="">10</option>
                                            <option value="">15</option>
                                            <option value="">20</option>
                                            <option value="">25</option>
                                            <option value="">30</option>
                                        </select>
                                    </div>
                                </div>
                                <div class="col-md-6 mt-auto">
                                    <button type="submit" class="btn themeBtn w-100">Find Collection Sites</button>
                                </div>
                            </div>
                        </form>
                    </div>
                </div>
            </div>
        </div>

    </div>
</div>
@endsection