{"id":1535,"date":"2022-02-09T15:11:26","date_gmt":"2022-02-09T15:11:26","guid":{"rendered":"https:\/\/helix4pain.com\/?page_id=1535"},"modified":"2022-02-09T15:13:12","modified_gmt":"2022-02-09T15:13:12","slug":"request-a-sample-1-mm","status":"publish","type":"page","link":"https:\/\/helix4pain.com\/professional\/request-a-sample-1-mm\/","title":{"rendered":"Request a Sample"},"content":{"rendered":"\n<p> Complete and submit this form for a sample of Helix\u2122 Professional Pain Relief <\/p>\n\n\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f410-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/wp-json\/wp\/v2\/pages\/1535#wpcf7-f410-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"410\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.8.7\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f410-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<div class=\"form-group\">\n<span class=\"wpcf7-form-control-wrap\" data-name=\"yourname\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" id=\"helix-form-name\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Your Name\" value=\"\" type=\"text\" name=\"yourname\" \/><\/span>\n<\/div>\n<div class=\"form-group\">\n<span class=\"wpcf7-form-control-wrap\" data-name=\"practice_area\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" id=\"helix-form-practice-area\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Title\" value=\"\" type=\"text\" name=\"practice_area\" \/><\/span>\n<\/div>\n<div class=\"form-group\">\n<span class=\"wpcf7-form-control-wrap\" data-name=\"practice_name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" id=\"helix-form-practice-name\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Practice Name\" value=\"\" type=\"text\" name=\"practice_name\" \/><\/span>\n<\/div>\n<div class=\"form-group\">\n<span class=\"wpcf7-form-control-wrap\" data-name=\"address\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" id=\"helix-form-address\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Address\" value=\"\" type=\"text\" name=\"address\" \/><\/span>\n<\/div>\n<div class=\"form-group\">\n<span class=\"wpcf7-form-control-wrap\" data-name=\"city\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" id=\"helix-form-city\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"City\" value=\"\" type=\"text\" name=\"city\" \/><\/span>\n<\/div>\n<div class=\"form-group\">\n<span class=\"wpcf7-form-control-wrap\" data-name=\"state\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required form-control\" id=\"helix-form-state\" aria-required=\"true\" aria-invalid=\"false\" name=\"state\"><option value=\"State\">State<\/option><option value=\"Alabama\">Alabama<\/option><option value=\"Alaska\">Alaska<\/option><option value=\"Arizona\">Arizona<\/option><option value=\"Arkansas\">Arkansas<\/option><option value=\"California\">California<\/option><option value=\"Colora&lt;\/div&gt;do\">Colora&lt;\/div&gt;do<\/option><option value=\"Connecticut\">Connecticut<\/option><option value=\"Delaware\">Delaware<\/option><option value=\"Washington DC\">Washington DC<\/option><option value=\"Florida\">Florida<\/option><option value=\"Georgia\">Georgia<\/option><option value=\"Hawaii\">Hawaii<\/option><option value=\"Idaho\">Idaho<\/option><option value=\"Illinois\">Illinois<\/option><option value=\"Indiana\">Indiana<\/option><option value=\"Iowa\">Iowa<\/option><option value=\"Kansas\">Kansas<\/option><option value=\"Kentucky\">Kentucky<\/option><option value=\"Louisiana\">Louisiana<\/option><option value=\"Maine\">Maine<\/option><option value=\"Maryland\">Maryland<\/option><option value=\"Massachusetts\">Massachusetts<\/option><option value=\"Michigan\">Michigan<\/option><option value=\"Minnesota\">Minnesota<\/option><option value=\"Mississippi\">Mississippi<\/option><option value=\"Missouri\">Missouri<\/option><option value=\"Montana\">Montana<\/option><option value=\"Nebraska\">Nebraska<\/option><option value=\"Nevada\">Nevada<\/option><option value=\"New Hampshire\">New Hampshire<\/option><option value=\"New Jersey\">New Jersey<\/option><option value=\"New Mexico\">New Mexico<\/option><option value=\"New York\">New York<\/option><option value=\"North Carolina\">North Carolina<\/option><option value=\"North Dakota\">North Dakota<\/option><option value=\"Ohio\">Ohio<\/option><option value=\"Oklahoma\">Oklahoma<\/option><option value=\"Oregon\">Oregon<\/option><option value=\"Pennsylvania\">Pennsylvania<\/option><option value=\"Rhode Island\">Rhode Island<\/option><option value=\"South Carolina\">South Carolina<\/option><option value=\"South Dakota\">South Dakota<\/option><option value=\"Tennessee\">Tennessee<\/option><option value=\"Texas\">Texas<\/option><option value=\"Utah\">Utah<\/option><option value=\"Vermont\">Vermont<\/option><option value=\"Virginia\">Virginia<\/option><option value=\"Washington\">Washington<\/option><option value=\"West Virginia\">West Virginia<\/option><option value=\"Wisconsin\">Wisconsin<\/option><option value=\"Wyoming\">Wyoming<\/option><\/select><\/span>\n<\/div>\n<div class=\"form-group\">\n<span class=\"wpcf7-form-control-wrap\" 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