HP Consultation Application - Alternity Healthcare

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margin-left: 0px;} h3 { color: black;}p { text-align: center}</style></head><body> <h1 data-drip-attribute="headline">High Performance Consultation Call </h1> <div data-drip-attribute="description"></div> <div> <h3><label for="drip-email">Email Address</label><br /> <input type="email" id="drip-email" name="fields[email]" value="" /> </div> <div> <h3><label for="drip-first-name">First Name</label><br /> <input type="text" id="drip-first-name" name="fields[first_name]" value="" /> </div> <div> <h3> <label for="drip-last-name">Last Name</label><br /> <input type="text" id="drip-last-name" name="fields[last_name]" value="" /> </div> <div> <h3><label for="drip-phone">Phone</label><br /> <input type="text" id="drip-phone" name="fields[phone]" value="" /> </div> <div> <h3><label for="drip-state">State or Province</label><br /> <input type="text" id="drip-state" name="fields[state]" value="" /> </div> <div> <h3><label for="drip-country">Country</label><br /> <input type="text" id="drip-country" name="fields[country]" value="" /> </div> <div> <h3><label for="drip-health-concerns">Main Health Concern or Goal</label><br /> <textarea id="drip-health-concerns" name="fields[health_concerns]" value="" /></textarea> </div> <div> <h3><label for="drip-investment">What are you willing and able to invest to achieve results?</label><br /> <input type="text" id="drip-investment" name="fields[investment]" value="" /> </div> <div> <h3> <label for="drip-why-ahc">Why do you think Alternity Healthcare is a good fit for you?</label><br /> <textarea id="drip-why-ahc" name="fields[why_ahc]" value="" /></textarea> </div> <div> <h3><label for="drip-clinic-or-virtual">Are you interested in virtual or in-office services</label><br /> <input type="text" id="drip-clinic-or-virtual" name="fields[clinic_or_virtual]" value="" /> </div> <div> <h3><label for="drip-additional-info">Anything more you would like us to know?</label><br /> <textarea id="drip-additional-info" name="fields[additional_info]" value="" /></textarea> </div> <div> <h3><label for="drip-referral">Referred by</label><br /> <input type="text" id="drip-referral" name="fields[referral]" value="" /> </div><p><b> We welcome all consultation requests. Because of the focus of our practice and its intimate nature, we choose to work only with those truly committed to achieving a high performance lifestyle.</b></p> <div> <input type="submit" name="submit" value="Apply for Consultation" data-drip-attribute="sign-up-button" /><h3/> </div></form>