<h4>Seus dados:</h4>

      <input type="text" name="nome" placeholder="Nome..." class="quote-form-element" />
      <input type="text" name="cidade" placeholder="Cidade/UF..." class="quote-form-element quote-form-client-email last" />
      <input type="text" name="telefone" placeholder="Telefone..." class="quote-form-element telefone" />
      <input type="text" name="email" placeholder="E-mail..." class="quote-form-element quote-form-client-email last contact_email"
                            />

      <h4>Política de Privacidade</h4>
     <div class="checkbox quote-form-element" data-checked="yes" data-name="Política de Privacidade">

       <span class="checkbox-status"><i class="fa fa-check"></i></span>
       <span class="checkbox-values">

       <span class="checkbox-value-checked" style="font-size: 12px">Li e aceito a politica de privacidade</span></a>
       <span class="checkbox-value-unchecked" id="no">Não aceito</span>
       </span>
      </div>

      <button class="button button-navy-blue send-quote" type="button">Simular meu consórcio <i class="fa fa-paper-plane-o"></i></button>

function Connect()
{
$dbhost = "localhost";
$dbuser = "xxxxx";
$dbpass = "xxxxx";
$dbname = "xxxxx";


$conn = new mysqli($dbhost, $dbuser, $dbpass, $dbname) or die($conn->connect_error);

return $conn;
}

?>

<?php


$conn     = Connect();
$nome     = $conn->real_escape_string($_POST['Nome']);
$cidade   = $conn->real_escape_string($_POST['cidade']);
$telefone = $conn->real_escape_string($_POST['telefone']);
$email    = $conn->real_escape_string($_POST['email']);
$query    = "INSERT into leads_cform (nome,cidade,telefone,email) VALUES('" . $nome . "','" . $cidade . "','" . $telefone . "','" . $email . "')";
$success  = $conn->query($query);


$conn->close();



        $title = 'Nova simulação via website';


        $headers = "MIME-Version: 1.1n".
                   "Content-type: text/html; charset=utf-8n".
                   "Content-Transfer-Encoding: 8bitn".
                    "From: ". $_POST['clientName'] ." <". $_POST['clientEmail'] .">n".
                   "Reply-to: ". $_POST['clientName'] ." <". $_POST['clientEmail'] .">n".
                   "Date: ". date( "r" ). "n";


        $values = $_POST['values'];


        $rows = '';
        if (count($values) > 0) {
        for( $i = 0; $i < count( $values ); $i++ ) {

            $rows .= '<tr>

                          <td style="width: 200px; font-weight: bold; border: 1px solid #eee; padding: 10px;">'. $values[$i]['name'] .'</td>
                          <td style="border: 1px solid #eee; padding: 10px;">'. $values[$i]['value'] .'</td>

                      </tr>';
        }


        $content = '<table style="width: 600px; font-size: 11px; border-collapse: collapse;">'. $rows .'</table>';


        $result = mail(
            OWNER_EMAIL,
            "=?UTF-8?B?". base64_encode( $title ) ."?=",
            $content,
            $headers
        );}


    break;