GRAND GIVEAWAY OFFER
We are giving away our special offer of our Veterinary Deciduous Canine Extraction Set. All you have to do is to fill the form by entering your details!
{{--
Also, make sure to do the following to grab more chances of winning!
The lucky winner will be announced on 18th June, 2021, 10am EST.
ENTER TO WIN
@include('includes.partials.messages')
{!! Form::open(array('method' => 'POST', 'id' => 'frm_enter_to_win')) !!}
{!! Form::label('email', 'Email Address:') !!} *
{!! Form::text('email', null, ['type' => 'email', 'required' => 'required', 'class' => 'form-control', 'placeholder' => 'Enter email address ...', 'id' => 'sp_email']) !!}
{!! Form::label('first_name', 'First Name:') !!} *
{!! Form::text('first_name', null,['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Enter first name ...']) !!}
{!! Form::label('last_name', 'Last Name:') !!} *
{!! Form::text('last_name', null,['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Enter last name ...']) !!}
{!! Form::label('company', 'Company/Institute:') !!} *
{!! Form::text('company', null,['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Enter company/institute name ...']) !!}
{!! Form::label('phone', 'Phone:') !!} *
{!! Form::text('phone', null,['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Enter phone ...']) !!}
{!! Form::label('address', 'Address:') !!} *
{!! Form::text('address', null,['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Enter address ...']) !!}
{!! Form::label('city', 'City:') !!} *
{!! Form::text('city', null,['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Enter city ...']) !!}
{!! Form::label('state', 'State:') !!} *
{!! Form::select('state',
$data['states']
,null
,['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Please Select ...']) !!}
{!! Form::label('zip', 'Zip / Post Code:') !!} *
{!! Form::text('zip', null,['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Enter zip / post code ...']) !!}
{!! Form::label('role', 'Your Role:') !!} *
{!! Form::select('role',
['Veterinarian' => 'Veterinarian', 'Dentist' => 'Dentist', 'Technician' => 'Technician', 'Office Manager' => 'Office Manager', 'Clinic Owner' => 'Clinic Owner', 'Associated with Hospital' => 'Associated with Hospital', 'Other' => 'Other']
,null
,['class'=>'form-control', 'required' => 'required', 'placeholder'=>'Please Select ...']) !!}
{!! Form::label('role', 'Your Speciality:') !!} *
{!! Form::select('speciality',
['Dental' => 'Dental', 'Orthopedic' => 'Orthopedic', 'Soft Tissue' => 'Soft Tissue', 'Spay Neuter' => 'Spay Neuter']
,null
,['id' => 'newsletter-speciality', 'class'=>'form-control', 'required' => 'required', 'placeholder' => 'Your speciality ...']) !!}
{!! Form::label('comments', 'Additional Comments:') !!}
{!! Form::textarea('comments', null,['class'=>'form-control', 'placeholder'=>'Additional Comments ...', 'rows' => '3']) !!}
Please fill complete details in order to make your entery eligible for the draw.