[formidable id=11]
<div class="frm_forms with_frm_style frm_style_formidable-style" id="frm_form_11_container" >
<form enctype="multipart/form-data" method="post" class="frm-show-form frm_js_validate frm_pro_form frm_ajax_submit " id="form_contact23" >
<div class="frm_form_fields ">
<fieldset>
<div class="frm_fields_container">
<input type="hidden" name="frm_action" value="create" />
<input type="hidden" name="form_id" value="11" />
<input type="hidden" name="frm_hide_fields_11" id="frm_hide_fields_11" value="" />
<input type="hidden" name="form_key" value="contact23" />
<input type="hidden" name="item_meta[0]" value="" />
<input type="hidden" id="frm_submit_entry_11" name="frm_submit_entry_11" value="5595a14724" /><input type="hidden" name="_wp_http_referer" value="/contact-us/" /><div id="frm_field_194_container" class="frm_form_field form-field frm_required_field frm_hidden_container frm_full">
<label for="field_qh4icy4" class="frm_primary_label">Name
<span class="frm_required">*</span>
</label>
<input type="text" id="field_qh4icy4" name="item_meta[194]" value="" placeholder="Name" data-reqmsg="This field cannot be blank." aria-required="true" data-invmsg="Name is invalid" aria-invalid="false" />
</div>
<div id="frm_field_195_container" class="frm_form_field form-field frm_required_field frm_hidden_container frm_full">
<label for="field_29yf4d4" class="frm_primary_label">Email
<span class="frm_required">*</span>
</label>
<input type="email" id="field_29yf4d4" name="item_meta[195]" value="" placeholder="Email" data-reqmsg="This field cannot be blank." aria-required="true" data-invmsg="Please enter a valid email address" aria-invalid="false" />
</div>
<div id="frm_field_196_container" class="frm_form_field form-field frm_hidden_container frm_full">
<label for="field_n57sl4" class="frm_primary_label">Phone Number
<span class="frm_required"></span>
</label>
<input type="text" id="field_n57sl4" name="item_meta[196]" value="" style="width:135px" placeholder="Phone" data-invmsg="Phone Number is invalid" class="auto_width" aria-invalid="false" />
</div>
<div id="frm_field_197_container" class="frm_form_field form-field frm_hidden_container frm_full">
<label for="field_9jv0r14" class="frm_primary_label">Message
<span class="frm_required"></span>
</label>
<textarea name="item_meta[197]" id="field_9jv0r14" rows="5" placeholder="Enter your message here" data-invmsg="Message is invalid" aria-invalid="false" ></textarea>
</div>
<input type="hidden" name="item_key" value="" />
<div class="frm_verify" >
<label for="frm_email_11">
If you are human, leave this field blank. </label>
<input type="email" class="frm_verify" id="frm_email_11" name="frm_verify" value="" />
</div>
<div class="frm_submit">
<input type="submit" value="Get My Free Consultation" class="frm_final_submit" formnovalidate="formnovalidate" />
<img class="frm_ajax_loading" src="https://www.peoplesintegrativemedicine.com/wp-content/plugins/formidable/images/ajax_loader.gif" alt="Sending" style="visibility:hidden;" />
</div></div>
</fieldset>
</div>
</form>
</div>
