{"id":17,"date":"2025-04-20T06:27:50","date_gmt":"2025-04-20T06:27:50","guid":{"rendered":"https:\/\/samples.epimax.co.uk\/?page_id=17"},"modified":"2025-11-25T09:35:39","modified_gmt":"2025-11-25T09:35:39","slug":"samples-form","status":"publish","type":"page","link":"https:\/\/samples.epimax.co.uk\/","title":{"rendered":"Samples Form"},"content":{"rendered":"\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-mbkxlttr-7b4fd26d4d0ae67b2e982caba1014896\">\n.avia-section.av-mbkxlttr-7b4fd26d4d0ae67b2e982caba1014896{\nbackground-color:#221e46;\nbackground-image:unset;\n}\n<\/style>\n<div id='av_section_1'  class='avia-section av-mbkxlttr-7b4fd26d4d0ae67b2e982caba1014896 main_color avia-section-small avia-no-border-styling  avia-builder-el-0  el_before_av_section  avia-builder-el-first  hcp-notice-block avia-bg-style-scroll container_wrap sidebar_right'  ><div class='container av-section-cont-open' ><main  role=\"main\" itemprop=\"mainContentOfPage\"  class='template-page content  av-content-small alpha units'><div class='post-entry post-entry-type-page post-entry-17'><div class='entry-content-wrapper clearfix'>\n<div  class='avia-builder-widget-area clearfix  avia-builder-el-1  avia-builder-el-no-sibling '><div id=\"custom_html-3\" class=\"widget_text widget clearfix widget_custom_html\"><div class=\"textwidget custom-html-widget\"><div class=\"hcp-only-notice container_wra\"><div class=\"container\">For UK Healthcare Professionals Only<\/div><\/div>\r\n<div class=\"adverse-effects\"><div class=\"container\">Adverse events reporting can be found at the bottom of the page. For more information about EPIMAX&reg;, <a href=\"https:\/\/epimax.co.uk\/health-care-professionals\/product-information\/\" style=\"color:#fff!important;text-decoration:underline;\">please click here<\/a> for product information.<\/div><\/div><\/div><\/div><\/div>\n\n<\/div><\/div><\/main><!-- close content main element --><\/div><\/div><div id='av_section_2'  class='avia-section av-1qr9t-c4469297250b4c88077eb541cd8018fc main_color avia-section-default avia-no-border-styling  avia-builder-el-2  el_after_av_section  avia-builder-el-last  avia-bg-style-scroll container_wrap sidebar_right'  ><div class='container av-section-cont-open' ><div class='template-page content  av-content-small alpha units'><div class='post-entry post-entry-type-page post-entry-17'><div class='entry-content-wrapper clearfix'>\n<div  class='flex_column av-1aejd-3c6177af025fe68c307c81b81eeb73ef av_one_fifth  avia-builder-el-3  el_before_av_three_fifth  avia-builder-el-first  first flex_column_div  '     ><\/div><div  class='flex_column av-rc71-a6efbcdfbfbf520240753d9b02afdb20 av_three_fifth  avia-builder-el-4  el_after_av_one_fifth  el_before_av_one_fifth  flex_column_div  '     ><section  class='av_textblock_section av-m9sg3ask-35bf95f4fa8b5b07cefde2fadd200578 '   itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div class='avia_textblock'  itemprop=\"text\" ><h2>Emollient Patient Demonstration<\/h2>\n<h3>Sample Request Form<\/h3>\n<p>If you are a healthcare professional and would like to order patient demonstration samples from our EPIMAX<sup>\u00ae<\/sup> range, for your patients, please complete the form below.<\/p>\n<\/div><\/section><br \/>\n\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-mbgnuuqq-0b26b756ebc136b8e4268b871c955ebd\">\n#top .hr.hr-invisible.av-mbgnuuqq-0b26b756ebc136b8e4268b871c955ebd{\nheight:20px;\n}\n<\/style>\n<div  class='hr av-mbgnuuqq-0b26b756ebc136b8e4268b871c955ebd hr-invisible  avia-builder-el-6  el_after_av_textblock  el_before_av_textblock '><span class='hr-inner '><span class=\"hr-inner-style\"><\/span><\/span><\/div><br \/>\n<section  class='av_textblock_section av-m9pa4rzw-61594edbcb00d3796a9d7df045547c6c '   itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div class='avia_textblock'  itemprop=\"text\" ><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is 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#112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><div id='gf_1' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_1' id='gform_1'  action='\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F17#gf_1' data-formid='1' novalidate>\t\t\t\t\t<div style=\"display: none !important;\" class=\"akismet-fields-container gf_invisible\" data-prefix=\"ak_\">\n\t\t\t\t\t\t<label>&#916;<textarea name=\"ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label>\n\t\t\t\t\t\t<input type=\"hidden\" id=\"ak_js_1\" name=\"ak_js\" value=\"2\" \/>\n\t\t\t\t\t\t<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\ndocument.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );\n\/* ]]> *\/\n<\/script>\n\n\t\t\t\t\t<\/div>\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_above description_above validation_above'><fieldset id=\"field_1_2\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name&nbsp;<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_2'>\n                            \n                            <span id='input_1_2_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_1_2_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_2.3' id='input_1_2_3' value='' tabindex='101'  aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_1_2_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_1_2_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_2.6' id='input_1_2_6' value='' tabindex='103'  aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_3'>Job Title or Speciality<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_1_3' type='text' value='' class='large'   tabindex='105'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_4\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_4'>Institution (if applicable)<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_1_4' type='text' value='' class='large'   tabindex='106'   aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_5\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Registered Council&nbsp;<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_1_5'>Please select which council you are a member of from the options below. You will then be prompted to input your registration number.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_5'>\n\t\t\t<div class='gchoice gchoice_1_5_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='GMC'  id='choice_1_5_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_1_5\" tabindex='107'  \/>\n\t\t\t\t\t<label for='choice_1_5_0' id='label_1_5_0' class='gform-field-label gform-field-label--type-inline'>GMC<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_5_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='GPhC'  id='choice_1_5_1' onchange='gformToggleRadioOther( this )'  tabindex='108'  \/>\n\t\t\t\t\t<label for='choice_1_5_1' id='label_1_5_1' class='gform-field-label gform-field-label--type-inline'>GPhC<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_5_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='NMC'  id='choice_1_5_2' onchange='gformToggleRadioOther( this )'  tabindex='109'  \/>\n\t\t\t\t\t<label for='choice_1_5_2' id='label_1_5_2' class='gform-field-label gform-field-label--type-inline'>NMC<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_5_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='GDC'  id='choice_1_5_3' onchange='gformToggleRadioOther( this )'  tabindex='110'  \/>\n\t\t\t\t\t<label for='choice_1_5_3' id='label_1_5_3' class='gform-field-label gform-field-label--type-inline'>GDC<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_5_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='GOC'  id='choice_1_5_4' onchange='gformToggleRadioOther( this )'  tabindex='111'  \/>\n\t\t\t\t\t<label for='choice_1_5_4' id='label_1_5_4' class='gform-field-label gform-field-label--type-inline'>GOC<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_5_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='HCPC'  id='choice_1_5_5' onchange='gformToggleRadioOther( this )'  tabindex='112'  \/>\n\t\t\t\t\t<label for='choice_1_5_5' id='label_1_5_5' class='gform-field-label gform-field-label--type-inline'>HCPC<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_5_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='PSNI'  id='choice_1_5_6' onchange='gformToggleRadioOther( this )'  tabindex='113'  \/>\n\t\t\t\t\t<label for='choice_1_5_6' id='label_1_5_6' class='gform-field-label gform-field-label--type-inline'>PSNI<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_6'>Registration number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_6'>Please provide your registration number to aid with the verification of your form submission.<\/div><div class='ginput_container ginput_container_text'><input name='input_6' id='input_1_6' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_6\" tabindex='114'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_11\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Delivery Address<\/h3><div class='gsection_description' id='gfield_description_1_11'>This must be a clinical address unless you work from a private practice<\/div><\/div><div id=\"field_1_8\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_8'>Department<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_1_8' type='text' value='' class='large'   tabindex='115'   aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_13\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address&nbsp;<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_1_13' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_13_1_container' >\n                                        <label for='input_1_13_1' id='input_1_13_1_label' class='gform-field-label gform-field-label--type-sub '>Hospital, surgery or clinic<\/label>\n                                        <input type='text' name='input_13.1' id='input_1_13_1' value='' tabindex='116'   aria-required='true'    \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_13_2_container' >\n                                        <label for='input_1_13_2' id='input_1_13_2_label' class='gform-field-label gform-field-label--type-sub '>Address<\/label>\n                                        <input type='text' name='input_13.2' id='input_1_13_2' value='' tabindex='117'    aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_13_3_container' >\n                                    <label for='input_1_13_3' id='input_1_13_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_13.3' id='input_1_13_3' value='' tabindex='118'   aria-required='true'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_13_4_container' >\n                                        <label for='input_1_13_4' id='input_1_13_4_label' class='gform-field-label gform-field-label--type-sub '>County<\/label>\n                                        <input type='text' name='input_13.4' id='input_1_13_4' value='' tabindex='120'     aria-required='true'    \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_13_5_container' >\n                                    <label for='input_1_13_5' id='input_1_13_5_label' class='gform-field-label gform-field-label--type-sub '>Post code<\/label>\n                                    <input type='text' name='input_13.5' id='input_1_13_5' value='' tabindex='121'   aria-required='true'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_13.6' id='input_1_13_6' value='United Kingdom' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_1_15\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_15'>Phone number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_1_15' type='text' value='' class='large'   tabindex='122'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_1\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_1'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_1' id='input_1_1' type='email' value='' class='large' tabindex='123'   aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_16\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Sample selection<\/h3><div class='gsection_description' id='gfield_description_1_16'>Minimum sample units: 5 (excluding EPIMAX Eyelid Ointment and EPIMAX Gentle Wash). For orders over 100 units per product, please contact your Key Account Manager.<br> \n<\/br>Please enter the quantity of free patient demonstration samples required: <\/div><\/div><div id=\"field_1_39\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-half gfield_html gfield_html_formatted field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><img decoding=\"async\" src=\"https:\/\/samples.epimax.co.uk\/wp-content\/uploads\/2025\/06\/moisturising-1.png\"style=\"width:200px;height:200px;><\/div><div id=\"field_1_23\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_23'>EPIMAX Moisturising Cream (15g)<\/label><div class='ginput_container ginput_container_number'><input name='input_23' id='input_1_23' type='number' step='any' min='5' max='100' value='' class='small' tabindex='124'     aria-invalid=\"false\" aria-describedby=\"gfield_instruction_1_23\" \/><div class='gfield_description instruction ' id='gfield_instruction_1_23'>Please enter a number from <strong>5<\/strong> to <strong>100<\/strong>.<\/div><\/div><\/div><div id=\"field_1_40\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><img decoding=\"async\" src=\"https:\/\/samples.epimax.co.uk\/wp-content\/uploads\/2025\/06\/original-1.png\"style=\"width:200px;height:200px;><\/div><div id=\"field_1_25\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_25'>EPIMAX Original Cream (15g)<\/label><div class='ginput_container ginput_container_number'><input name='input_25' id='input_1_25' type='number' step='any' min='5' max='100' value='' class='small' tabindex='125'     aria-invalid=\"false\" aria-describedby=\"gfield_instruction_1_25\" \/><div class='gfield_description instruction ' id='gfield_instruction_1_25'>Please enter a number from <strong>5<\/strong> to <strong>100<\/strong>.<\/div><\/div><\/div><div id=\"field_1_41\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><img decoding=\"async\" src=\"https:\/\/samples.epimax.co.uk\/wp-content\/uploads\/2025\/06\/oatmeal-1.png\"style=\"width:200px;height:200px;><\/div><div id=\"field_1_26\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_26'>EPIMAX Oatmeal Cream (15g)<\/label><div class='ginput_container ginput_container_number'><input name='input_26' id='input_1_26' type='number' step='any' min='5' max='100' value='' class='small' tabindex='126'     aria-invalid=\"false\" aria-describedby=\"gfield_instruction_1_26\" \/><div class='gfield_description instruction ' id='gfield_instruction_1_26'>Please enter a number from <strong>5<\/strong> to <strong>100<\/strong>.<\/div><\/div><\/div><div id=\"field_1_42\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><img decoding=\"async\" src=\"https:\/\/samples.epimax.co.uk\/wp-content\/uploads\/2025\/06\/excetra-1.png\"style=\"width:200px;height:200px;><\/div><div id=\"field_1_27\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_27'>EPIMAX Excetra Cream (15g)<\/label><div class='ginput_container ginput_container_number'><input name='input_27' id='input_1_27' type='number' step='any' min='5' max='100' value='' class='small' tabindex='127'     aria-invalid=\"false\" aria-describedby=\"gfield_instruction_1_27\" \/><div class='gfield_description instruction ' id='gfield_instruction_1_27'>Please enter a number from <strong>5<\/strong> to <strong>100<\/strong>.<\/div><\/div><\/div><div id=\"field_1_43\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><img decoding=\"async\" src=\"https:\/\/samples.epimax.co.uk\/wp-content\/uploads\/2025\/06\/isomol-1.png\"style=\"width:200px;height:200px;><\/div><div id=\"field_1_28\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_28'>EPIMAX Isomol Gel (15g)<\/label><div class='ginput_container ginput_container_number'><input name='input_28' id='input_1_28' type='number' step='any' min='5' max='100' value='' class='small' tabindex='128'     aria-invalid=\"false\" aria-describedby=\"gfield_instruction_1_28\" \/><div class='gfield_description instruction ' id='gfield_instruction_1_28'>Please enter a number from <strong>5<\/strong> to <strong>100<\/strong>.<\/div><\/div><\/div><div id=\"field_1_44\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><img decoding=\"async\" src=\"https:\/\/samples.epimax.co.uk\/wp-content\/uploads\/2025\/06\/ointment-1.png\"style=\"width:200px;height:200px;><\/div><div id=\"field_1_29\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_29'>EPIMAX Ointment (25g)<\/label><div class='ginput_container ginput_container_number'><input name='input_29' id='input_1_29' type='number' step='any' min='5' max='100' value='' class='small' tabindex='129'     aria-invalid=\"false\" aria-describedby=\"gfield_instruction_1_29\" \/><div class='gfield_description instruction ' id='gfield_instruction_1_29'>Please enter a number from <strong>5<\/strong> to <strong>100<\/strong>.<\/div><\/div><\/div><div id=\"field_1_45\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><img decoding=\"async\" src=\"https:\/\/samples.epimax.co.uk\/wp-content\/uploads\/2025\/06\/PF-Ointment.png\"style=\"width:200px;height:200px;><\/div><div id=\"field_1_30\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_30'>EPIMAX Paraffin-Free Ointment (25g)<\/label><div class='ginput_container ginput_container_number'><input name='input_30' id='input_1_30' type='number' step='any' min='5' max='100' value='' class='small' tabindex='130'     aria-invalid=\"false\" aria-describedby=\"gfield_instruction_1_30\" \/><div class='gfield_description instruction ' id='gfield_instruction_1_30'>Please enter a number from <strong>5<\/strong> to <strong>100<\/strong>.<\/div><\/div><\/div><div id=\"field_1_46\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><img decoding=\"async\" src=\"https:\/\/samples.epimax.co.uk\/wp-content\/uploads\/2025\/06\/EPIMAX-Eyelid-Ointment-Tube-and-Box-1.png\"style=\"width:200px;height:200px;><\/div><div id=\"field_1_31\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_above gfield--has-description field_description_below field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_31'>EPIMAX Eyelid Ointment (4g)<\/label><div class='ginput_container ginput_container_number'><input name='input_31' id='input_1_31' type='number' step='any' min='1' max='5' value='' class='small' tabindex='131'     aria-invalid=\"false\" aria-describedby=\"gfield_instruction_1_31 gfield_description_1_31\" \/><div class='gfield_description instruction ' id='gfield_instruction_1_31'>Please enter a number from <strong>1<\/strong> to <strong>5<\/strong>.<\/div><\/div><div class='gfield_description' id='gfield_description_1_31'>Maximum 5 per request<\/div><\/div><div id=\"field_1_48\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-half gfield_html gfield_html_formatted field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><img decoding=\"async\" src=\"https:\/\/samples.epimax.co.uk\/wp-content\/uploads\/2025\/09\/EPIMAX-Gentle-Wash.png\"style=\"width:200px;height:200px;><\/div><div id=\"field_1_49\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_above gfield--has-description field_description_below field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_49'>EPIMAX Gentle Wash (500g)<\/label><div class='ginput_container ginput_container_number'><input name='input_49' id='input_1_49' type='number' step='any' min='1' max='1' value='' class='small' tabindex='132'     aria-invalid=\"false\" aria-describedby=\"gfield_instruction_1_49 gfield_description_1_49\" \/><div class='gfield_description instruction ' id='gfield_instruction_1_49'>Please enter a number from <strong>1<\/strong> to <strong>1<\/strong>.<\/div><\/div><div class='gfield_description' id='gfield_description_1_49'>Maximum 1 per request<\/div><\/div><fieldset id=\"field_1_33\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I am a Healthcare Professional&nbsp;<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_1_33' tabindex='0'>I hereby declare that I am a qualified Healthcare Professional and that the samples I am requesting may be used for patient demonstration purposes and will not be made available for re-sale. I accept Aspire Pharma Ltd\u2019s <a href=\"https:\/\/aspirepharma.co.uk\/data-protection\"\/><font color='blue'> Data Protection Policy<\/font><\/a> and <a href=\"https:\/\/aspirepharma.co.uk\/terms-and-conditions\/\"\/><font color='blue'>Terms and Conditions<\/font><\/a>. <\/div><div class='ginput_container ginput_container_consent'><input name='input_33.1' id='input_1_33_1' type='checkbox' value='1' tabindex='133' aria-describedby=\"gfield_consent_description_1_33\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_33_1' >Yes<\/label><input type='hidden' name='input_33.2' value='Yes' class='gform_hidden' \/><input type='hidden' name='input_33.3' value='6' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_1_47\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_47'>Key Account Manager<\/label><div class='gfield_description' id='gfield_description_1_47'>If you have spoken to or been in contact with an Aspire Pharma Key Account Manager, please select their name from the options below: <\/div><div class='ginput_container ginput_container_select'><select name='input_47' id='input_1_47' class='large gfield_select' tabindex='134' aria-describedby=\"gfield_description_1_47\"   aria-invalid=\"false\" ><option value='' ><\/option><option value='Andrew Stephenson' >Andrew Stephenson<\/option><option value='Anil Makwana' >Anil Makwana<\/option><option value='Claire Espie' >Claire Espie<\/option><option value='Darren Rosevear' >Darren Rosevear<\/option><option value='Gary Grimsey' >Gary Grimsey<\/option><option value='Karen Wade' >Karen Wade<\/option><option value='Laura Mason' >Laura Mason<\/option><option value='Sean Fitzpatrick' >Sean Fitzpatrick<\/option><\/select><\/div><\/div><fieldset id=\"field_1_32\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Stay Informed<\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_1_32' tabindex='0'>I confirm that I am a registered healthcare professional and consent to receive both promotional and non-promotional information, including educational resources and medicine updates from Aspire Pharma via email and post. Copies of the privacy policy are available at: <a href=\"https:\/\/aspirepharma.co.uk\/data-protection\"\/><font color='blue'>aspirepharma.co.uk\/data-protection<\/font><\/a>. I understand that I can opt out at any time by emailing: <a href=\"mailto:marketing.info@aspirepharma.com.\"\/><font color='blue'>marketing.info@aspirepharma.com<\/font><\/a>. <\/div><div class='ginput_container ginput_container_consent'><input name='input_32.1' id='input_1_32_1' type='checkbox' value='1' tabindex='135' aria-describedby=\"gfield_consent_description_1_32\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_32_1' >Yes<\/label><input type='hidden' name='input_32.2' value='Yes' class='gform_hidden' \/><input type='hidden' name='input_32.3' value='6' class='gform_hidden' \/><\/div><\/fieldset><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_1' class='gform_button button gform-button--width-full' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit' tabindex='136' \/> <input type='hidden' name='gform_ajax' value='form_id=1&amp;title=&amp;description=&amp;tabindex=100&amp;theme=orbital&amp;styles=[]&amp;hash=1caba4ef205f8380e1a257cc9289a910' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_1' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_1' id='gform_theme_1' value='orbital' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_1' id='gform_style_settings_1' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='1' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='GBP' value='5eRvYvX+EV8RjlPH4dhRmlW0NT9zHBy87lbPel3v+snhyDSmnyeVI6X9Wwod4UGFO\/18yqNnza0+WVwJl9qTXGwP\/GW1fPZtA8L9n4HraXj5kIw=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' 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