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maximus87

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maximus87
Sep 19th, 2024
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  1. <div class="form-container" style="box-sizing: border-box; background-color: #fff; border-radius: 8px 8px 8px 8px; padding: 20px 30px 20px 30px;">
  2. <h3 style="text-align: center;">Take the First Step!</h3>
  3. <form accept-charset="UTF-8" action="https://crm.zoho.com/crm/WebToLeadForm" method="POST" name="WebToLeads2370202000105625061">
  4. <div style="display: none;"><input style="display: none;" name="xnQsjsdp" type="text" value="b574da28aa1c2a477068d7f08519ddd4708c4fb11ca53e74a87eb38516b1342b" />
  5. <input id="zc_gad" name="zc_gad" type="hidden" value="" />
  6. <input style="display: none;" name="xmIwtLD" type="text" value="6ec3cb70201e74fe8c575898b000d2d717e144f06b8b1810c7c8687ff6df47d4" />
  7. <input style="display: none;" name="actionType" type="text" value="TGVhZHM=" />
  8. <input style="display: none;" name="returnURL" type="text" value="https://mexicobariatriccenter.com/thank-you-for-your-interest/" />
  9. <input id="ldeskuid" style="display: none;" name="ldeskuid" type="text" />
  10. <input id="LDTuvid" style="display: none;" name="LDTuvid" type="text" /></div>
  11. <ul style="list-style: none; padding: 0px 0px 0px 0px; margin: 0;">
  12. <li style="list-style-type: none;"><label style="font-size: 15px; font-weight: 600; color: #041c3a; padding: 0 0px 0px 0px;" for="First Name">First Name:</label>
  13. <ul style="list-style: none; padding: 0px 0px 0px 0px; margin: 0;">
  14. <li style="background: #f1f1f1; resize: none; box-sizing: content-box; display: block; padding: 4px; margin-bottom: 14px; margin-top: 3px; border-radius: 5px; box-shadow: 0px 1px 2px 0px #465b89a6 inset;"><input id="firstname" style="background: #f1f1f1; resize: none; box-sizing: border-box; -webkit-box-sizing: border-box; -moz-box-sizing: border-box; width: 100%; display: block; outline: none; border: none; line-height: 25px; height: 42px; font-size: 16px; padding: 0 0px 0px 10px;" maxlength="100" name="First Name" required="" type="text" value="" /></li>
  15. </ul>
  16. </li>
  17. <li style="list-style-type: none;"><label style="font-size: 15px; font-weight: 600; color: #041c3a; padding: 0 0px 0px 0px;" for="Last Name">Last Name:</label>
  18. <ul style="list-style: none; padding: 0px 0px 0px 0px; margin: 0;">
  19. <li style="background: #f1f1f1; box-sizing: content-box; display: block; padding: 4px; margin-bottom: 14px; margin-top: 3px; border-radius: 5px; box-shadow: 0px 1px 2px 0px #465b89a6 inset;"><input id="lastname" style="background: #f1f1f1; resize: none; box-sizing: border-box; -webkit-box-sizing: border-box; -moz-box-sizing: border-box; width: 100%; display: block; outline: none; border: none; line-height: 25px; height: 42px; font-size: 16px; padding: 0 0px 0px 10px;" maxlength="100" name="Last Name" required="" type="text" value="" /></li>
  20. </ul>
  21. </li>
  22. <li style="list-style-type: none;"><label style="font-size: 15px; font-weight: 600; color: #041c3a; padding: 0 0px 0px 0px;" for="Email">Email:</label>
  23. <ul style="list-style: none; padding: 0px 0px 0px 0px; margin: 0;">
  24. <li style="background: #f1f1f1; box-sizing: content-box; display: block; padding: 4px; margin-bottom: 14px; margin-top: 3px; border-radius: 5px; box-shadow: 0px 1px 2px 0px #465b89a6 inset;"><input id="email" style="background: #f1f1f1; resize: none; box-sizing: border-box; -webkit-box-sizing: border-box; -moz-box-sizing: border-box; width: 100%; display: block; outline: none; border: none; line-height: 25px; height: 42px; font-size: 16px; padding: 0 0px 0px 10px;" maxlength="100" name="Email" required="" type="text" value="" /></li>
  25. </ul>
  26. </li>
  27. <li style="list-style-type: none;"><label style="font-size: 15px; font-weight: 600; color: #041c3a; padding: 0 0px 0px 0px;" for="Phone">Phone:</label>
  28. <ul style="list-style: none; padding: 0px 0px 0px 0px; margin: 0;">
  29. <li style="background: #f1f1f1; box-sizing: content-box; display: block; padding: 4px; margin-bottom: 26px; margin-top: 3px; border-radius: 5px; box-shadow: 0px 1px 2px 0px #465b89a6 inset;"><input id="phone" style="background: #f1f1f1; resize: none; box-sizing: border-box; -webkit-box-sizing: border-box; -moz-box-sizing: border-box; width: 100%; display: block; outline: none; border: none; line-height: 25px; height: 42px; font-size: 16px; padding: 0 0px 0px 10px;" maxlength="100" name="Phone" required="" type="text" value="" /></li>
  30. </ul>
  31. </li>
  32. </ul>
  33. <table style="display: none;">
  34. <tbody>
  35. <tr style="display: none;">
  36. <td style="nowrap: nowrap; text-align: left; font-size: 12px; font-family: Arial; width: 50%;">Company Channel</td>
  37. <td style="width: 250px;"><select style="width: 250px;" name="LEADCF27">
  38. <option selected="selected" value="MBC">MBC</option>
  39. </select></td>
  40. </tr>
  41. <tr style="display: none;">
  42. <td style="nowrap: nowrap; text-align: left; font-size: 12px; font-family: Arial; width: 50%;">Lead Form</td>
  43. <td style="width: 250px;"><select style="width: 250px;" name="LEADCF26">
  44. <option selected="selected" value="Short Form">Short Form</option>
  45. </select></td>
  46. </tr>
  47. <tr style="display: none;">
  48. <td style="nowrap: nowrap; text-align: left; font-size: 12px; font-family: Arial; width: 50%;">UTM Source</td>
  49. <td style="width: 250px;"><input id="utmcsr" style="width: 250px;" maxlength="255" name="LEADCF6" type="text" value="" /></td>
  50. </tr>
  51. <tr style="display: none;">
  52. <td style="nowrap: nowrap; text-align: left; font-size: 12px; font-family: Arial; width: 50%;">UTM Medium</td>
  53. <td style="width: 250px;"><input id="utmcmd" style="width: 250px;" maxlength="255" name="LEADCF8" type="text" value="" /></td>
  54. </tr>
  55. <tr style="display: none;">
  56. <td style="nowrap: nowrap; text-align: left; font-size: 12px; font-family: Arial; width: 50%;">UTM Campaign</td>
  57. <td style="width: 250px;"><input id="utmccn" style="width: 250px;" maxlength="255" name="LEADCF2" type="text" value="" /></td>
  58. </tr>
  59. <tr style="display: none;">
  60. <td style="nowrap: nowrap; text-align: left; font-size: 12px; font-family: Arial; width: 50%;">UTM Content</td>
  61. <td style="width: 250px;"><input id="utmcct" style="width: 250px;" maxlength="255" name="LEADCF7" type="text" value="" /></td>
  62. </tr>
  63. <tr style="display: none;">
  64. <td style="nowrap: nowrap; text-align: left; font-size: 12px; font-family: Arial; width: 50%;">UTM Term</td>
  65. <td style="width: 250px;"><input id="utmctr" style="width: 250px;" maxlength="255" name="LEADCF14" type="text" value="" /></td>
  66. </tr>
  67. <tr style="display: none;">
  68. <td style="nowrap: nowrap; text-align: left; font-size: 12px; font-family: Arial; width: 50%;">Page URL</td>
  69. <td style="width: 250px;"><input id="referrer" style="width: 250px;" maxlength="255" name="LEADCF5" type="text" value="mexicobariatriccenter.com" /></td>
  70. </tr>
  71. <tr style="display: none;">
  72. <td style="nowrap: nowrap; text-align: left; font-size: 12px; font-family: Arial; width: 50%;">IP Address</td>
  73. <td style="width: 250px;"><input id="ip" style="width: 250px;" maxlength="255" name="LEADCF1" type="text" value="" /></td>
  74. </tr>
  75. </tbody>
  76. </table>
  77. <ul style="list-style: none; padding: 0px 0px 0px 0px; margin: 0;">
  78. <li style="display: block; padding: 0px; border-radius: 4px; border: none; margin-top: 22px; margin-bottom: 0px; text-align: center;"><input id="formsubmit" style="border-radius: 8px; border: 1px #DD1062; background: #DD1062; color: #fff; font-size: 21px; letter-spacing: 0.1px; font-weight: bold; height: 54px; padding: 12px;" type="submit" value="Contact Us!" /></li>
  79. </ul>
  80. </form></div>
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