call-back-form

[et_pb_section fb_built=”1″ background_color=”#e1f4f3″ _builder_version=”3.12.2″][et_pb_row custom_width_percent=”50%” _builder_version=”3.12.2″][et_pb_column type=”4_4″ _builder_version=”3.12.2″ parallax=”off” parallax_method=”on”][et_pb_code max_width=”50%” _builder_version=”3.12.2″ module_alignment=”center” max_width_last_edited=”on|phone” max_width_tablet=”75%” max_width_phone=”100%”]<form accept-charset="UTF-8" action="https://icosmetic.karenbetts.com/kbp_enquiry_form.php" class="infusion-form" method="POST"><!– [et_pb_line_break_holder] –> <!–form accept-charset="UTF-8" action="https://icosmetic.karenbetts.com/kbp_news_letter.php" class="infusion-form" method="POST"–><!– [et_pb_line_break_holder] –> <input name="inf_form_xid" value="26a2e19ec0fc7141fc6e972499bbfff8" type="hidden"><!– [et_pb_line_break_holder] –> <input name="inf_form_name" value="Karen Betts Arrange A Call Back Form" type="hidden"><!– [et_pb_line_break_holder] –> <input name="infusionsoft_version" value="1.48.0.46" type="hidden"><!– [et_pb_line_break_holder] –> <div class="container"><!– [et_pb_line_break_holder] –> <div class="row"><!– [et_pb_line_break_holder] –> <div class="col-md-12 col-xs-12"><!– [et_pb_line_break_holder] –> <div class="form-group"><!– [et_pb_line_break_holder] –> <label for="inf_field_FirstName" class="form-label">First Name</label><!– [et_pb_line_break_holder] –> <input class="myFormField form-control animatelabel" placeholder="First Name" id="inf_field_FirstName" name="inf_field_FirstName" type="text"><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> <div class="form-group"><!– [et_pb_line_break_holder] –> <label for="inf_field_LastName" class="form-label">Surname</label><!– [et_pb_line_break_holder] –> <input class="myFormField form-control animatelabel" placeholder="Surname" id="inf_field_LastName" name="inf_field_LastName" type="text"><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> <div class="form-group"><!– [et_pb_line_break_holder] –> <label for="inf_field_Phone1" class="form-label">Phone Number</label><!– [et_pb_line_break_holder] –> <input class="myFormField form-control animatelabel" placeholder="Phone Number" id="inf_field_Phone1" name="inf_field_Phone1" type="text"><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> <div class="col-md-12 col-xs-12"><!– [et_pb_line_break_holder] –> <div class="form-group"><!– [et_pb_line_break_holder] –> <label for="inf_field_Email" class="form-label">Email Address</label><!– [et_pb_line_break_holder] –> <input class="myFormField form-control animatelabel" placeholder="Email Address" id="inf_field_Email" name="inf_field_Email" type="text"><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> <div class="form-group"><!– [et_pb_line_break_holder] –> <label for="inf_field_EmailAddress2" class="form-label">Confirm Email Address</label><!– [et_pb_line_break_holder] –> <input class="myFormField form-control animatelabel" placeholder="Confirm Email Address" id="inf_field_EmailAddress2" name="inf_field_EmailAddress2" type="text"><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> <div class="form-group"><!– [et_pb_line_break_holder] –> <label for="inf_field_City" class="form-label">City</label><!– [et_pb_line_break_holder] –> <input class="myFormField form-control animatelabel" placeholder="City" id="inf_field_City" name="inf_field_City" type="text"><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –><!– [et_pb_line_break_holder] –> <div class="row"><!– [et_pb_line_break_holder] –> <div class="col-md-12 col-sm-4 col-xs-12"><!– [et_pb_line_break_holder] –> <p class="check-label"><!– [et_pb_line_break_holder] –> I am interested in:<!– [et_pb_line_break_holder] –> </p><!– [et_pb_line_break_holder] –> <div class="checkbox"><!– [et_pb_line_break_holder] –> <label><!– [et_pb_line_break_holder] –> <input id="inf_option_GeneralEnquiry" name="inf_option_GeneralEnquiry" value="4331" type="checkbox"><!– [et_pb_line_break_holder] –> General enquiry<!– [et_pb_line_break_holder] –> </label><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> <div class="checkbox"><!– [et_pb_line_break_holder] –> <label><!– [et_pb_line_break_holder] –> <input id="inf_option_BrowTreatments" name="inf_option_BrowTreatments" value="4333" type="checkbox"><!– [et_pb_line_break_holder] –> Brow treatments<!– [et_pb_line_break_holder] –> </label><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> <div class="checkbox"><!– [et_pb_line_break_holder] –> <label><!– [et_pb_line_break_holder] –> <input id="inf_option_EyeTreatments" name="inf_option_EyeTreatments" value="4335" type="checkbox"><!– [et_pb_line_break_holder] –> Eye treatments<!– [et_pb_line_break_holder] –> </label><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> <div class="checkbox"><!– [et_pb_line_break_holder] –> <label><!– [et_pb_line_break_holder] –> <input id="inf_option_LipTreatments" name="inf_option_LipTreatments" value="4337" type="checkbox"><!– [et_pb_line_break_holder] –> Lip treatments<!– [et_pb_line_break_holder] –> </label><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> <div class="checkbox"><!– [et_pb_line_break_holder] –> <label><!– [et_pb_line_break_holder] –> <input id="inf_option_MedicalTreatments" name="inf_option_MedicalTreatments" value="4339" type="checkbox"><!– [et_pb_line_break_holder] –> Medical treatments<!– [et_pb_line_break_holder] –> </label><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> <div class="col-md-12 col-sm-8 col-xs-12" style="text-align: left;"><!– [et_pb_line_break_holder] –> <div class="form-group"><!– [et_pb_line_break_holder] –> <label class="check-label" for="inf_custom_Comments">Comments:</label><!– [et_pb_line_break_holder] –> <textarea class="myFormField form-control" id="inf_custom_Comments" name="inf_custom_Comments" rows="7" cols="30"></textarea><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –><!– [et_pb_line_break_holder] –> <div class="row preferences-row"><!– [et_pb_line_break_holder] –> <div class="col-md-12 col-sm-6 col-xs-12"><!– [et_pb_line_break_holder] –> <p class="check-label"><!– [et_pb_line_break_holder] –> You will be contacted via either email, SMS, telephone or mail regarding, training, products, promotional offers and discounts. Please choose your preferences.<!– [et_pb_line_break_holder] –> </p><!– [et_pb_line_break_holder] –> <div class="checkbox-inline-wrap"><!– [et_pb_line_break_holder] –> <div class="checkbox-inline text-center"><!– [et_pb_line_break_holder] –> <label><!– [et_pb_line_break_holder] –> <input id="marketing[sms]" name="marketing_sms" value="1" type="checkbox"><!– [et_pb_line_break_holder] –> SMS<!– [et_pb_line_break_holder] –> </label><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> <div class="checkbox-inline text-center"><!– [et_pb_line_break_holder] –> <label><!– [et_pb_line_break_holder] –> <input id="marketing[phone]" name="marketing_phone" value="1" type="checkbox"><!– [et_pb_line_break_holder] –> Phone<!– [et_pb_line_break_holder] –> </label><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> <div class="checkbox-inline text-center"><!– [et_pb_line_break_holder] –> <label><!– [et_pb_line_break_holder] –> <input id="marketing[email]" name="marketing_email" value="1" type="checkbox"><!– [et_pb_line_break_holder] –> Email<!– [et_pb_line_break_holder] –> </label><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> <div class="checkbox-inline text-center"><!– [et_pb_line_break_holder] –> <label><!– [et_pb_line_break_holder] –> <input id="marketing[mail]" name="marketing_mail" value="1" type="checkbox"><!– [et_pb_line_break_holder] –> Mail<!– [et_pb_line_break_holder] –> </label><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> <div class="col-md-12 col-sm-6 col-xs-12"><!– [et_pb_line_break_holder] –> <div class="g-recaptcha" data-sitekey="6LfLt3UUAAAAALC6WrRXQCSHETUXD72oGS56Nfq0"><div style="width: 304px; height: 78px;"><div><iframe src="https://www.google.com/recaptcha/api2/anchor?ar=1&k=6LfLt3UUAAAAALC6WrRXQCSHETUXD72oGS56Nfq0&co=aHR0cHM6Ly93d3cua2FyZW5iZXR0cy5jb206NDQz&hl=en&v=v1543818755456&size=normal&cb=yuprr4b54za3" role="presentation" name="a-19x69y17a40f" scrolling="no" sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox allow-storage-access-by-user-activation" width="304" height="78" frameborder="0"></iframe></div><textarea id="g-recaptcha-response" name="g-recaptcha-response" class="g-recaptcha-response" style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea></div></div><!– [et_pb_line_break_holder] –> <input class="header-button form-submit" value="SUBMIT" type="submit"><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –><!– [et_pb_line_break_holder] –> </form>[/et_pb_code][/et_pb_column][/et_pb_row][/et_pb_section]