{"id":3771,"date":"2021-08-18T21:24:02","date_gmt":"2021-08-18T15:54:02","guid":{"rendered":"https:\/\/bentley-sutures.com\/dental\/?page_id=3771"},"modified":"2023-11-11T18:27:16","modified_gmt":"2023-11-11T12:57:16","slug":"samples","status":"publish","type":"page","link":"https:\/\/bentley-sutures.com\/dental\/samples\/","title":{"rendered":"Samples"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"3771\" class=\"elementor elementor-3771\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-87a6a1f elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"87a6a1f\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-08d34f9\" data-id=\"08d34f9\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-eb8814c elementor-widget elementor-widget-image\" data-id=\"eb8814c\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" width=\"150\" height=\"150\" src=\"https:\/\/i0.wp.com\/bentley-sutures.com\/dental\/wp-content\/uploads\/2023\/11\/Try-Before-You-Buy-e1699706841684.webp?resize=150%2C150&amp;ssl=1\" class=\"attachment-thumbnail size-thumbnail wp-image-6351\" alt=\"\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-fbec67a elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"fbec67a\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-8d35e7e\" data-id=\"8d35e7e\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-f73e801 elementor-align-center elementor-widget elementor-widget-button\" data-id=\"f73e801\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-md\" href=\"\/dental\/dental_college_registration\/\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Click here if you are requesting samples for a Dental College<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-510f996 elementor-widget elementor-widget-heading\" data-id=\"510f996\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h3 class=\"elementor-heading-title elementor-size-default\">Request for Samples<\/h3>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-4d85858 elementor-widget elementor-widget-heading\" data-id=\"4d85858\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-small\">Only for Registered Medical Practitioners <br>(Dentists, Oral &amp; Maxillofacial Surgeons)<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-daac146 elementor-widget elementor-widget-wpforms\" data-id=\"daac146\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"wpforms.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-3794\"><form id=\"wpforms-form-3794\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"3794\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/dental\/wp-json\/wp\/v2\/pages\/3771\" data-token=\"465a01c9ad6d8e4c7b6f7733d98db0b9\" data-token-time=\"1781537409\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-3794-field_12-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-3794-field_12\">Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-3794-field_12\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][12]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-3794-field_1-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-3794-field_1\">Full Name <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3794-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" required><\/div><div id=\"wpforms-3794-field_2-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-3794-field_2\">Phone No. <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3794-field_2\" class=\"wpforms-field-medium wpforms-field-required wpforms-limit-characters-enabled\" data-form-id=\"3794\" data-field-id=\"2\" data-text-limit=\"30\" name=\"wpforms[fields][2]\" placeholder=\"10 digit mobile no.\" maxlength=\"30\" required><\/div><div id=\"wpforms-3794-field_3-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"3\"><label class=\"wpforms-field-label wpforms-label-hide\">Gender <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3794-field_3\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3794-field_3_1\" name=\"wpforms[fields][3]\" value=\"Male\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3794-field_3_1\">Male<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3794-field_3_2\" name=\"wpforms[fields][3]\" value=\"Female\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3794-field_3_2\">Female<\/label><\/li><\/ul><\/div><div id=\"wpforms-3794-field_5-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-3794-field_5\">Degrees<\/label><input type=\"text\" id=\"wpforms-3794-field_5\" class=\"wpforms-field-medium\" name=\"wpforms[fields][5]\" ><\/div><div id=\"wpforms-3794-field_6-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-3794-field_6\">Medical Council Reg. No. <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3794-field_6\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][6]\" required><\/div><div id=\"wpforms-3794-field_4-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-modern\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-3794-field_4\">Specialization <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-3794-field_4\" class=\"wpforms-field-small wpforms-field-required choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-small\" data-search-enabled=\"\" name=\"wpforms[fields][4][]\" required=\"required\" multiple=\"multiple\"><option value=\"\" class=\"placeholder\" disabled ><\/option><option value=\"Periodontist\"  class=\"choice-4 depth-1\"  >Periodontist<\/option><option value=\"Prosthodontist\"  class=\"choice-5 depth-1\"  >Prosthodontist<\/option><option value=\"Oral &amp; Maxillofacial Surgery\"  class=\"choice-6 depth-1\"  >Oral &amp; Maxillofacial Surgery<\/option><option value=\"Orthodontist\"  class=\"choice-7 depth-1\"  >Orthodontist<\/option><option value=\"Endodontist\"  class=\"choice-8 depth-1\"  >Endodontist<\/option><option value=\"Pedodontist\"  class=\"choice-9 depth-1\"  >Pedodontist<\/option><option value=\"Other\"  class=\"choice-10 depth-1\"  >Other<\/option><\/select><\/div><div id=\"wpforms-3794-field_7-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-3794-field_7\">Clinic \/ Hospital \/ Firm Name (optional)<\/label><input type=\"text\" id=\"wpforms-3794-field_7\" class=\"wpforms-field-large\" name=\"wpforms[fields][7]\" ><\/div><div id=\"wpforms-3794-field_8-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-3794-field_8\">Address Line 1 <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3794-field_8\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][8]\" required><\/div><div id=\"wpforms-3794-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-3794-field_9\">Address line 2<\/label><input type=\"text\" id=\"wpforms-3794-field_9\" class=\"wpforms-field-large\" name=\"wpforms[fields][9]\" ><\/div><div id=\"wpforms-3794-field_10-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-3794-field_10\">Town \/ City name <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3794-field_10\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][10]\" required><\/div><div id=\"wpforms-3794-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-3794-field_11\">Zip code \/ Pin code <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3794-field_11\" class=\"wpforms-field-small wpforms-field-required wpforms-masked-input\" data-rule-inputmask-incomplete=\"1\" data-inputmask-mask=\"999999\" name=\"wpforms[fields][11]\" required><\/div><div id=\"wpforms-3794-field_17-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"17\"><label class=\"wpforms-field-label\">Suture sizes that you use most often (select any two)<\/label><ul id=\"wpforms-3794-field_17\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-3794-field_17_1\" name=\"wpforms[fields][17][]\" value=\"3-0\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3794-field_17_1\">3-0<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-3794-field_17_2\" name=\"wpforms[fields][17][]\" value=\"4-0\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3794-field_17_2\">4-0<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-3794-field_17_3\" name=\"wpforms[fields][17][]\" value=\"5-0\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3794-field_17_3\">5-0<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-3794-field_17_4\" name=\"wpforms[fields][17][]\" value=\"6-0\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3794-field_17_4\">6-0<\/label><\/li><\/ul><\/div><div id=\"wpforms-3794-field_18-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"18\"><label class=\"wpforms-field-label\">Suture materials that you use most often (select upto three max)<\/label><ul id=\"wpforms-3794-field_18\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-3794-field_18_1\" name=\"wpforms[fields][18][]\" value=\"Silk\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3794-field_18_1\">Silk<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-3794-field_18_2\" name=\"wpforms[fields][18][]\" value=\"Polypropylene\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3794-field_18_2\">Polypropylene<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-3794-field_18_3\" name=\"wpforms[fields][18][]\" value=\"Nylon (Polyamide)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3794-field_18_3\">Nylon (Polyamide)<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-3794-field_18_4\" name=\"wpforms[fields][18][]\" value=\"Absorbable Polyglactin-910 (Violet)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3794-field_18_4\">Absorbable Polyglactin-910 (Violet)<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-3794-field_18_5\" name=\"wpforms[fields][18][]\" value=\"Absorbable Polyglactin-910 Fast Absorbing (undyed)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3794-field_18_5\">Absorbable Polyglactin-910 Fast Absorbing (undyed)<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-3794-field_18_6\" name=\"wpforms[fields][18][]\" value=\"Monofilament Absorbable Poliglecaprone-25 (undyed)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3794-field_18_6\">Monofilament Absorbable Poliglecaprone-25 (undyed)<\/label><\/li><\/ul><\/div><div id=\"wpforms-3794-field_28-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"28\"><label class=\"wpforms-field-label\">On an average, how many sutures do you use per month. <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-3794-field_28\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3794-field_28_1\" name=\"wpforms[fields][28]\" value=\"1-5 nos\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3794-field_28_1\">1-5 nos<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3794-field_28_2\" name=\"wpforms[fields][28]\" value=\"6-10 nos\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3794-field_28_2\">6-10 nos<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-3794-field_28_3\" name=\"wpforms[fields][28]\" value=\"11-15 nos\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3794-field_28_3\">11-15 nos<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-3794-field_28_4\" name=\"wpforms[fields][28]\" value=\"16-20 nos\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3794-field_28_4\">16-20 nos<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-3794-field_28_5\" name=\"wpforms[fields][28]\" value=\"20-30 nos \" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3794-field_28_5\">20-30 nos<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-3794-field_28_6\" name=\"wpforms[fields][28]\" value=\"above 30 nos\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3794-field_28_6\">above 30 nos<\/label><\/li><\/ul><\/div><div id=\"wpforms-3794-field_29-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-modern\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-3794-field_29\">Select your choice of free samples (any two) <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-3794-field_29\" class=\"wpforms-field-medium wpforms-field-required choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"1\" name=\"wpforms[fields][29][]\" required=\"required\" multiple=\"multiple\"><option value=\"\" class=\"placeholder\" disabled >select any 2<\/option><option value=\"Silk 3-0, with Medium (20-22mm) needle\"  class=\"choice-1 depth-1\"  >Silk 3-0, with Medium (20-22mm) needle<\/option><option value=\"Silk 3-0, with Long (24-26mm) needle\"  class=\"choice-2 depth-1\"  >Silk 3-0, with Long (24-26mm) needle<\/option><option value=\"Absorbable Polyglactin-910 (3-0) with Medium (20-22mm) needle\"  class=\"choice-3 depth-1\"  >Absorbable Polyglactin-910 (3-0) with Medium (20-22mm) needle<\/option><option value=\"Fast Absorbable Polyglactin-910 (3-0) with Medium (20-22mm) needle\"  class=\"choice-5 depth-1\"  >Fast Absorbable Polyglactin-910 (3-0) with Medium (20-22mm) needle<\/option><option value=\"Fast Absorbable Polyglactin-910 (3-0) with Long (24-26mm) needle\"  class=\"choice-6 depth-1\"  >Fast Absorbable Polyglactin-910 (3-0) with Long (24-26mm) needle<\/option><option value=\"Polyamide(Nylon) 3-0 with Long 26mm needle \"  class=\"choice-8 depth-1\"  >Polyamide(Nylon) 3-0 with Long 26mm needle<\/option><option value=\"Polyamide(Nylon) 4-0 with small 10mm Rev. Cutting needle\"  class=\"choice-12 depth-1\"  >Polyamide(Nylon) 4-0 with small 10mm Rev. Cutting needle<\/option><option value=\"Polyamide(Nylon) 5-0 with 16mm cutting needle\"  class=\"choice-13 depth-1\"  >Polyamide(Nylon) 5-0 with 16mm cutting needle<\/option><option value=\"Polypropylene 5-0 with 13mm needle\"  class=\"choice-10 depth-1\"  >Polypropylene 5-0 with 13mm needle<\/option><option value=\"Polypropylene 4-0 with 15-17mm needle\"  class=\"choice-11 depth-1\"  >Polypropylene 4-0 with 15-17mm needle<\/option><\/select><\/div><div id=\"wpforms-3794-field_23-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-modern\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-3794-field_23\">How did you know about us?<\/label><select id=\"wpforms-3794-field_23\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"1\" name=\"wpforms[fields][23]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'><\/option><option value=\"I was referred to you by a colleague\"  class=\"choice-1 depth-1\"  >I was referred to you by a colleague<\/option><option value=\"Facebook Ad\"  class=\"choice-2 depth-1\"  >Facebook Ad<\/option><option value=\"Instagram Ad\"  class=\"choice-3 depth-1\"  >Instagram Ad<\/option><option value=\"Magazine Ad\"  class=\"choice-8 depth-1\"  >Magazine Ad<\/option><option value=\"Google search \"  class=\"choice-7 depth-1\"  >Google search<\/option><option value=\"WhatsApp message\"  class=\"choice-4 depth-1\"  >WhatsApp message<\/option><option value=\"Email message\"  class=\"choice-5 depth-1\"  >Email message<\/option><option value=\"Company Sales Representative\"  class=\"choice-6 depth-1\"  >Company Sales Representative<\/option><\/select><\/div><div id=\"wpforms-3794-field_24-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-3794-field_24\">Mention the referral code\/name\/phone (any one) of the colleague who referred you to us.<\/label><input type=\"text\" id=\"wpforms-3794-field_24\" class=\"wpforms-field-medium\" name=\"wpforms[fields][24]\" ><div class=\"wpforms-field-description\">Refer us to your 5 of your colleagues and upon successful registrations by them, you get 1 full box (12 sutures) of Silk sutures (Size 3-0 or 4-0)  Worth MRP Rs. 1620.00 FREE of cost.<\/div><\/div><div id=\"wpforms-3794-field_13-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-3794-field_13\">Comments (if any)<\/label><textarea id=\"wpforms-3794-field_13\" class=\"wpforms-field-medium\" name=\"wpforms[fields][13]\" ><\/textarea><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-recaptcha-container wpforms-is-recaptcha wpforms-is-recaptcha-type-v2\" ><div class=\"g-recaptcha\" data-sitekey=\"6LfkWfgaAAAAAEULv9oDVXjBnhuJPsqv8zEMk9IA\"><\/div><input type=\"text\" name=\"g-recaptcha-hidden\" 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