{"id":4923,"date":"2023-12-01T13:28:18","date_gmt":"2023-12-01T21:28:18","guid":{"rendered":"https:\/\/acufastneedles.com\/?page_id=4923"},"modified":"2026-03-23T11:25:40","modified_gmt":"2026-03-23T18:25:40","slug":"draft-page","status":"publish","type":"page","link":"https:\/\/acufastneedles.com\/fr\/draft-page\/","title":{"rendered":"Draft Page"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container has-pattern-background has-mask-background nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1216.8px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:15px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:15px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form fusion-form-builder fusion-form-form-wrapper fusion-form-5335\" style=\"--awb-tooltip-text-color:#ffffff;--awb-tooltip-background-color:var(--awb-color4);--awb-field-margin-top:10px;--awb-field-margin-bottom:0px;--awb-form-font-size:16px;--awb-form-placeholder-color:hsla(var(--awb-color6-h),var(--awb-color6-s),var(--awb-color6-l),calc(var(--awb-color6-a) - 50%));--awb-form-text-color:var(--awb-color6);--awb-form-border-color:var(--awb-color5);--awb-form-focus-border-color:var(--awb-color5);--awb-form-focus-border-hover-color:hsla(var(--awb-color5-h),var(--awb-color5-s),var(--awb-color5-l),calc(var(--awb-color5-a) - 50%));\" data-form-id=\"5335\" data-config=\"{&quot;form_id&quot;:&quot;5335&quot;,&quot;form_post_id&quot;:&quot;5335&quot;,&quot;post_id&quot;:4923,&quot;form_type&quot;:&quot;post&quot;,&quot;confirmation_type&quot;:[&quot;redirect&quot;],&quot;redirect_url&quot;:&quot;https:\\\/\\\/acufastneedles.com\\\/samples-request-confirm\\\/&quot;,&quot;redirect_timeout&quot;:&quot;0&quot;,&quot;field_labels&quot;:{&quot;first_name&quot;:&quot;First Name&quot;,&quot;last_name&quot;:&quot;Last Name&quot;,&quot;email&quot;:&quot;Email&quot;,&quot;license_status&quot;:&quot;I am a:&quot;,&quot;license_no&quot;:&quot;License #&quot;,&quot;practitioner_type&quot;:&quot;What type of Practitioner are you?&quot;,&quot;clinic_name&quot;:&quot;Clinic Name&quot;,&quot;school_name&quot;:&quot;Name of School You&#039;re Currently Enrolled In&quot;,&quot;approved_school&quot;:&quot;Approved School&quot;,&quot;student_type&quot;:&quot;What type of Student are you?&quot;,&quot;clinic_school_location&quot;:&quot;Clinic or School Location&quot;,&quot;supplier&quot;:&quot;Where do you regularly buy your clinic supplies from?&quot;,&quot;sample_pack&quot;:&quot;Choose Your Sample Pack&quot;,&quot;tubes&quot;:&quot;Do you require guide tubes?&quot;,&quot;street_address&quot;:&quot;Street Address&quot;,&quot;city&quot;:&quot;City&quot;,&quot;state_province&quot;:&quot;State \\\/ Province \\\/ Region&quot;,&quot;zip_postal&quot;:&quot;Zip \\\/ Postal Code&quot;,&quot;country&quot;:&quot;Country&quot;,&quot;referral&quot;:&quot;How did you hear about Acufast Earth Friendly Needles?&quot;},&quot;field_logics&quot;:{&quot;first_name&quot;:&quot;&quot;,&quot;last_name&quot;:&quot;&quot;,&quot;email&quot;:&quot;&quot;,&quot;license_status&quot;:&quot;&quot;,&quot;license_no&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;license_status\\&quot;,\\&quot;value\\&quot;:\\&quot;Practitioner\\&quot;}]&quot;,&quot;practitioner_type&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;license_status\\&quot;,\\&quot;value\\&quot;:\\&quot;Practitioner\\&quot;}]&quot;,&quot;clinic_name&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;license_status\\&quot;,\\&quot;value\\&quot;:\\&quot;Practitioner\\&quot;}]&quot;,&quot;school_name&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;license_status\\&quot;,\\&quot;value\\&quot;:\\&quot;Student\\&quot;}]&quot;,&quot;approved_school&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;license_status\\&quot;,\\&quot;value\\&quot;:\\&quot;Student\\&quot;}]&quot;,&quot;student_type&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;license_status\\&quot;,\\&quot;value\\&quot;:\\&quot;Student\\&quot;}]&quot;,&quot;clinic_school_location&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;or\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;license_status\\&quot;,\\&quot;value\\&quot;:\\&quot;Practitioner\\&quot;},{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;license_status\\&quot;,\\&quot;value\\&quot;:\\&quot;Student\\&quot;}]&quot;,&quot;supplier&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;or\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;license_status\\&quot;,\\&quot;value\\&quot;:\\&quot;Practitioner\\&quot;},{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;license_status\\&quot;,\\&quot;value\\&quot;:\\&quot;Student\\&quot;}]&quot;,&quot;sample_pack&quot;:&quot;&quot;,&quot;tubes&quot;:&quot;&quot;,&quot;street_address&quot;:&quot;&quot;,&quot;city&quot;:&quot;&quot;,&quot;state_province&quot;:&quot;&quot;,&quot;zip_postal&quot;:&quot;&quot;,&quot;country&quot;:&quot;&quot;,&quot;referral&quot;:&quot;&quot;,&quot;submit_1&quot;:&quot;&quot;},&quot;field_types&quot;:{&quot;first_name&quot;:&quot;text&quot;,&quot;last_name&quot;:&quot;text&quot;,&quot;email&quot;:&quot;email&quot;,&quot;license_status&quot;:&quot;radio&quot;,&quot;license_no&quot;:&quot;text&quot;,&quot;practitioner_type&quot;:&quot;select&quot;,&quot;clinic_name&quot;:&quot;text&quot;,&quot;school_name&quot;:&quot;text&quot;,&quot;approved_school&quot;:&quot;radio&quot;,&quot;student_type&quot;:&quot;select&quot;,&quot;clinic_school_location&quot;:&quot;select&quot;,&quot;supplier&quot;:&quot;text&quot;,&quot;sample_pack&quot;:&quot;radio&quot;,&quot;tubes&quot;:&quot;radio&quot;,&quot;street_address&quot;:&quot;text&quot;,&quot;city&quot;:&quot;text&quot;,&quot;state_province&quot;:&quot;text&quot;,&quot;zip_postal&quot;:&quot;text&quot;,&quot;country&quot;:&quot;text&quot;,&quot;referral&quot;:&quot;select&quot;,&quot;submit_1&quot;:&quot;submit&quot;},&quot;nonce_method&quot;:&quot;ajax&quot;,&quot;form_views&quot;:&quot;ajax&quot;,&quot;form_views_counting&quot;:&quot;all&quot;}\"><form action=\"https:\/\/script.google.com\/macros\/s\/AKfycbyuJGVNRRLPoAF0hPSozGL53OQoF1mWVncM1iQdZLGkfWmZKernkG_iqr9CV1zFg4ky\/exec\" method=\"post\" class=\"fusion-form fusion-form-5335\"><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-1 fusion-flex-container has-pattern-background has-mask-background nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"width:calc( 100% + 20px ) !important;max-width:calc( 100% + 20px ) !important;margin-left: calc(-20px \/ 2 );margin-right: calc(-20px \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:15px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:15px;--awb-spacing-left-large:10px;--awb-width-medium:50%;--awb-order-medium:0;--awb-flex-grow-medium:;--awb-flex-shrink-medium:;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:;--awb-flex-shrink-small:;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"5335\"><div class=\"fusion-form-label-wrapper\"><label for=\"first_name\">First Name <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\"  data-empty-notice=\"Field cannot be blank\" name=\"first_name\" id=\"first_name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:15px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:15px;--awb-spacing-left-large:10px;--awb-width-medium:50%;--awb-order-medium:0;--awb-flex-grow-medium:;--awb-flex-shrink-medium:;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:;--awb-flex-shrink-small:;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"5335\"><div class=\"fusion-form-label-wrapper\"><label for=\"last_name\">Last Name <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\"  data-empty-notice=\"Field cannot be blank\" name=\"last_name\" id=\"last_name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-3 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:15px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:15px;--awb-spacing-left-large:10px;--awb-width-medium:50%;--awb-order-medium:0;--awb-flex-grow-medium:;--awb-flex-shrink-medium:;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:;--awb-flex-shrink-small:;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-email-field fusion-form-label-above\" style=\"\" data-form-id=\"5335\"><div class=\"fusion-form-label-wrapper\"><label for=\"email\">Email <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"email\" autocomplete=\"off\"  data-empty-notice=\"Field cannot be blank.\" name=\"email\" id=\"email\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-4 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:15px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:15px;--awb-spacing-left-large:10px;--awb-width-medium:50%;--awb-order-medium:0;--awb-flex-grow-medium:;--awb-flex-shrink-medium:;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:;--awb-flex-shrink-small:;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" style=\"\" data-form-id=\"5335\"><fieldset><legend class=\"fusion-form-label-wrapper\"><span class=\"label\">I am a: <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/legend><div class=\"fusion-form-radio option-inline\"><input data-empty-notice=\"Please select one.\" tabindex=\"\" id=\"radio-license_status-1-0\" type=\"radio\" value=\"Practitioner\" name=\"license_status\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-license_status-1-0\">Practitioner<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input data-empty-notice=\"Please select one.\" tabindex=\"\" id=\"radio-license_status-1-1\" type=\"radio\" value=\"Student\" name=\"license_status\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-license_status-1-1\">Student<\/label><\/div><\/fieldset><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-5 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:15px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:15px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:;--awb-flex-shrink-medium:;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:;--awb-flex-shrink-small:;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"5335\" data-form-element-name=\"text_3\"><div class=\"fusion-form-label-wrapper\"><label for=\"license_no\">License # <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"license_no\" id=\"license_no\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-select-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"5335\" data-form-element-name=\"select_1\"><label for=\"practitioner_type\">What type of Practitioner are you? <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><div class=\"fusion-select-wrapper\"><select autocomplete=\"off\" tabindex=\"\" id=\"practitioner_type\" name=\"practitioner_type\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"><option value=\"\" disabled selected>What type of practitioner are you?<\/option><option value=\"Acupuncturist\" >Acupuncturist<\/option><option value=\"TCM Practitioner\" >TCM Practitioner<\/option><option value=\"Naturopathic Doctor\" >Naturopathic Doctor<\/option><option value=\"Physiotherapist\" >Physiotherapist<\/option><option value=\"Chiropractic Doctor\" >Chiropractic Doctor<\/option><option value=\"Veterinarian\" >Veterinarian<\/option><option value=\"Medical Doctor\" >Medical Doctor<\/option><option value=\"Massage Therapist\" >Massage Therapist<\/option><option value=\"Other\" >Other<\/option><\/select><div class=\"select-arrow\"><svg width=\"12\" height=\"8\" viewBox=\"0 0 12 8\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"> <path d=\"M1.5 1.75L6 6.25L10.5 1.75\" stroke=\"#6D6D6D\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\"\/> <\/svg><\/div><\/div><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"5335\" data-form-element-name=\"text_4\"><div class=\"fusion-form-label-wrapper\"><label for=\"clinic_name\">Clinic Name<\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"clinic_name\" id=\"clinic_name\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-6 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:15px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:15px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:;--awb-flex-shrink-medium:;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:;--awb-flex-shrink-small:;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"5335\" data-form-element-name=\"text_5\"><div class=\"fusion-form-label-wrapper\"><label for=\"school_name\">Name of School You&#039;re Currently Enrolled In <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"school_name\" id=\"school_name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"5335\" data-form-element-name=\"radio_2\"><fieldset><legend class=\"fusion-form-label-wrapper\"><span class=\"label\">Approved School <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><div class=\"fusion-form-tooltip\"><i class=\"awb-icon-question-circle\"><\/i><span class=\"fusion-form-tooltip-content\">Please confirm that the school or program you are currently enrolled in is recognized by the applicapble licensing body of the country you will be practicing in.<\/span><\/div><\/legend><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-approved_school-2-0\" type=\"radio\" value=\"Yes\" name=\"approved_school\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-approved_school-2-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-approved_school-2-1\" type=\"radio\" value=\"No\" name=\"approved_school\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-approved_school-2-1\">No<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-approved_school-2-2\" type=\"radio\" value=\"Unsure\" name=\"approved_school\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-approved_school-2-2\">Unsure<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-select-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"5335\" data-form-element-name=\"select_2\"><label for=\"student_type\">What type of Student are you? <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><div class=\"fusion-select-wrapper\"><select autocomplete=\"off\" tabindex=\"\" id=\"student_type\" name=\"student_type\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"><option value=\"\" disabled selected>What type of student are you?<\/option><option value=\"Acupuncturist\" >Acupuncturist<\/option><option value=\"TCM Practitioner\" >TCM Practitioner<\/option><option value=\"Naturopathic Doctor\" >Naturopathic Doctor<\/option><option value=\"Physiotherapist\" >Physiotherapist<\/option><option value=\"Chiropractic Doctor\" >Chiropractic Doctor<\/option><option value=\"Veterinarian\" >Veterinarian<\/option><option value=\"Medical Doctor\" >Medical Doctor<\/option><option value=\"Massage Therapist\" >Massage Therapist<\/option><option value=\"Other\" >Other<\/option><\/select><div class=\"select-arrow\"><svg width=\"12\" height=\"8\" viewBox=\"0 0 12 8\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"> <path d=\"M1.5 1.75L6 6.25L10.5 1.75\" stroke=\"#6D6D6D\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\"\/> <\/svg><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-7 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:15px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:15px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:;--awb-flex-shrink-medium:;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:;--awb-flex-shrink-small:;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-select-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"5335\" data-form-element-name=\"select_3\"><label for=\"clinic_school_location\">Clinic or School Location <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><div class=\"fusion-form-tooltip\"><i class=\"awb-icon-question-circle\"><\/i><span class=\"fusion-form-tooltip-content\">This will determine which Acufast distributor will send your samples. Please note, samples are limited to North American and European countries at the moment.<\/span><\/div><div class=\"fusion-select-wrapper\"><select autocomplete=\"off\" tabindex=\"\" id=\"clinic_school_location\" name=\"clinic_school_location\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"><option value=\"\" disabled selected>Please choose a country\/region<\/option><option value=\"Canada\" >Canada<\/option><option value=\"United States\" >United States<\/option><option value=\"Europe\" >Europe<\/option><option value=\"United Kingdom\" >United Kingdom<\/option><\/select><div class=\"select-arrow\"><svg width=\"12\" height=\"8\" viewBox=\"0 0 12 8\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"> <path d=\"M1.5 1.75L6 6.25L10.5 1.75\" stroke=\"#6D6D6D\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\"\/> <\/svg><\/div><\/div><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"5335\" data-form-element-name=\"text_6\"><div class=\"fusion-form-label-wrapper\"><label for=\"supplier\">Where do you regularly buy your clinic supplies from?<\/label><\/div><input type=\"text\" autocomplete=\"off\" name=\"supplier\" id=\"supplier\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-8 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-padding-top:5%;--awb-padding-right:5%;--awb-padding-bottom:5%;--awb-padding-left:5%;--awb-overflow:hidden;--awb-bg-color:#ecf0f5;--awb-bg-color-hover:#ecf0f5;--awb-bg-size:cover;--awb-border-color:var(--awb-color4);--awb-border-top:1px;--awb-border-right:1px;--awb-border-bottom:1px;--awb-border-left:1px;--awb-border-style:solid;--awb-border-radius:6px 6px 6px 6px;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:15px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:15px;--awb-spacing-left-large:0px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:;--awb-flex-shrink-medium:;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:0px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:;--awb-flex-shrink-small:;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-1\"><p data-fusion-font=\"true\" data-fusion-google-font=\"Source Sans 3\" data-fusion-google-variant=\"400\" style=\"font-weight: 400;\">Your Acufast Needle Sample Pack will come with 3 sizes of coated needles, an Acuclip, and tubes if you require them. <\/p>\n<\/div><div class=\"fusion-builder-row fusion-builder-row-inner fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"--awb-min-height:no;--awb-min-height-medium:no;--awb-min-height-small:no;--awb-flex-grow:undefined;--awb-flex-grow-medium:undefined;--awb-flex-grow-small:undefined;--awb-flex-shrink:undefined;--awb-flex-shrink-medium:undefined;--awb-flex-shrink-small:undefined;width:calc( 100% + 20px ) !important;max-width:calc( 100% + 20px ) !important;margin-left: calc(-20px \/ 2 );margin-right: calc(-20px \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-0 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:33.333333333333%;--awb-margin-top-large:15px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:15px;--awb-spacing-left-large:10px;--awb-width-medium:33.333333333333%;--awb-order-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-2\"><p><b>Standard Pack Needle Sizes:<\/b><br \/>.20 x 30mm, .25 x 40mm, .25 x 50mm<\/p>\n<\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-1 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:33.333333333333%;--awb-margin-top-large:15px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:15px;--awb-spacing-left-large:10px;--awb-width-medium:33.333333333333%;--awb-order-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-3\"><p><b>Sports  Pack Needle Sizes:<\/b><br \/>.25 x 30mm, .30 x 40mm, .30 x 50mm<\/p>\n<\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-2 fusion_builder_column_inner_1_3 1_3 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:33.333333333333%;--awb-margin-top-large:15px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:15px;--awb-spacing-left-large:10px;--awb-width-medium:33.333333333333%;--awb-order-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-4\"><p><b>Facial Pack Needle Sizes:<\/b><br \/>.16 x 15mm, .16 x 30mm, .18 x 30mm<\/p>\n<\/div><\/div><\/div><\/div><div class=\"fusion-text fusion-text-5\"><p data-fusion-font=\"true\" data-fusion-google-font=\"Source Sans 3\" data-fusion-google-variant=\"400\" style=\"font-weight: 400;\">Please select your preferred sample pack from the options below:<\/p>\n<\/div><div class=\"fusion-builder-row fusion-builder-row-inner fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"--awb-min-height:no;--awb-min-height-medium:no;--awb-min-height-small:no;--awb-flex-grow:undefined;--awb-flex-grow-medium:undefined;--awb-flex-grow-small:undefined;--awb-flex-shrink:undefined;--awb-flex-shrink-medium:undefined;--awb-flex-shrink-small:undefined;width:calc( 100% + 20px ) !important;max-width:calc( 100% + 20px ) !important;margin-left: calc(-20px \/ 2 );margin-right: calc(-20px \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-3 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:15px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:15px;--awb-spacing-left-large:10px;--awb-width-medium:50%;--awb-order-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" style=\"\" data-form-id=\"5335\"><fieldset><legend class=\"fusion-form-label-wrapper\"><span class=\"label\">Choose Your Sample Pack <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/legend><div class=\"fusion-form-radio option-inline\"><input data-empty-notice=\"Please make a selection\" tabindex=\"\" id=\"radio-sample_pack-3-0\" type=\"radio\" value=\"Standard Pack\" name=\"sample_pack\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-sample_pack-3-0\">Standard Pack<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input data-empty-notice=\"Please make a selection\" tabindex=\"\" id=\"radio-sample_pack-3-1\" type=\"radio\" value=\"Sports Pack\" name=\"sample_pack\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-sample_pack-3-1\">Sports Pack<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input data-empty-notice=\"Please make a selection\" tabindex=\"\" id=\"radio-sample_pack-3-2\" type=\"radio\" value=\"Facial Pack\" name=\"sample_pack\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-sample_pack-3-2\">Facial Pack<\/label><\/div><\/fieldset><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-4 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:15px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:15px;--awb-spacing-left-large:10px;--awb-width-medium:50%;--awb-order-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" style=\"\" data-form-id=\"5335\"><fieldset><legend class=\"fusion-form-label-wrapper\"><span class=\"label\">Do you require guide tubes? <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/legend><div class=\"fusion-form-radio option-inline\"><input data-empty-notice=\"Please make a selection\" tabindex=\"\" id=\"radio-tubes-4-0\" type=\"radio\" value=\"Yes\" name=\"tubes\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-tubes-4-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input data-empty-notice=\"Please make a selection\" tabindex=\"\" id=\"radio-tubes-4-1\" type=\"radio\" value=\"No\" name=\"tubes\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-tubes-4-1\">No<\/label><\/div><\/fieldset><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-9 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:15px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:15px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:;--awb-flex-shrink-medium:;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:;--awb-flex-shrink-small:;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-6\"><p data-fusion-font=\"true\" data-fusion-google-font=\"Source Sans 3\" data-fusion-google-variant=\"400\" style=\"font-weight: 400;\">Where should we mail your samples?<\/p>\n<\/div>\n<div class=\"fusion-builder-row fusion-builder-row-inner fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"--awb-min-height:no;--awb-min-height-medium:no;--awb-min-height-small:no;--awb-flex-grow:undefined;--awb-flex-grow-medium:undefined;--awb-flex-grow-small:undefined;--awb-flex-shrink:undefined;--awb-flex-shrink-medium:undefined;--awb-flex-shrink-small:undefined;width:calc( 100% + 20px ) !important;max-width:calc( 100% + 20px ) !important;margin-left: calc(-20px \/ 2 );margin-right: calc(-20px \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-5 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:15px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:15px;--awb-spacing-left-large:10px;--awb-width-medium:50%;--awb-order-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"5335\"><div class=\"fusion-form-label-wrapper\"><label for=\"street_address\">Street Address <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\"  data-empty-notice=\"Field cannot be blank.\" name=\"street_address\" id=\"street_address\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-6 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:15px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:15px;--awb-spacing-left-large:10px;--awb-width-medium:50%;--awb-order-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"5335\"><div class=\"fusion-form-label-wrapper\"><label for=\"city\">City <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\"  data-empty-notice=\"Field cannot be blank.\" name=\"city\" id=\"city\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><\/div><div class=\"fusion-builder-row fusion-builder-row-inner fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"--awb-min-height:no;--awb-min-height-medium:no;--awb-min-height-small:no;--awb-flex-grow:0;--awb-flex-grow-medium:0;--awb-flex-grow-small:0;--awb-flex-shrink:0;--awb-flex-shrink-medium:0;--awb-flex-shrink-small:0;width:calc( 100% + 20px ) !important;max-width:calc( 100% + 20px ) !important;margin-left: calc(-20px \/ 2 );margin-right: calc(-20px \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-7 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:15px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:15px;--awb-spacing-left-large:10px;--awb-width-medium:50%;--awb-order-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"5335\"><div class=\"fusion-form-label-wrapper\"><label for=\"state_province\">State \/ Province \/ Region <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\"  data-empty-notice=\"Field cannot be blank.\" name=\"state_province\" id=\"state_province\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-8 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:15px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:15px;--awb-spacing-left-large:10px;--awb-width-medium:50%;--awb-order-medium:0;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"5335\"><div class=\"fusion-form-label-wrapper\"><label for=\"zip_postal\">Zip \/ Postal Code <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\"  data-empty-notice=\"Field cannot be blank.\" name=\"zip_postal\" id=\"zip_postal\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"5335\"><div class=\"fusion-form-label-wrapper\"><label for=\"country\">Country <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\"  data-empty-notice=\"Field cannot be blank.\" name=\"country\" id=\"country\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-10 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:15px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:15px;--awb-spacing-left-large:10px;--awb-width-medium:50%;--awb-order-medium:0;--awb-flex-grow-medium:;--awb-flex-shrink-medium:;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:;--awb-flex-shrink-small:;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-select-field fusion-form-label-above\" style=\"\" data-form-id=\"5335\"><label for=\"referral\">How did you hear about Acufast Earth Friendly Needles? <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><div class=\"fusion-select-wrapper\"><select autocomplete=\"off\" data-empty-notice=\"Please make a selection\" tabindex=\"\" id=\"referral\" name=\"referral\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"><option value=\"\" disabled selected>Please let us know how you heard of Acufast.<\/option><option value=\"Instagram\" >Instagram<\/option><option value=\"A friend\/colleague referred me\" >A friend\/colleague referred me<\/option><option value=\"My school\" >My school<\/option><option value=\"Conference or Seminar\" >Conference or Seminar<\/option><option value=\"Qiological Podcast\" >Qiological Podcast<\/option><option value=\"Print Advertisement\" >Print Advertisement<\/option><option value=\"Facebook\" >Facebook<\/option><option value=\"Google Search\" >Google Search<\/option><option value=\"AI Chat Search\" >AI Chat Search<\/option><option value=\"Other\" >Other<\/option><\/select><div class=\"select-arrow\"><svg width=\"12\" height=\"8\" viewBox=\"0 0 12 8\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"> <path d=\"M1.5 1.75L6 6.25L10.5 1.75\" stroke=\"#6D6D6D\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\"\/> <\/svg><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-11 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:15px;--awb-spacing-right-large:10px;--awb-margin-bottom-large:15px;--awb-spacing-left-large:10px;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:;--awb-flex-shrink-medium:;--awb-spacing-right-medium:10px;--awb-spacing-left-medium:10px;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:;--awb-flex-shrink-small:;--awb-spacing-right-small:10px;--awb-spacing-left-small:10px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow 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