<div class="postformoptin1"><!-- [et_pb_line_break_holder] --><div class="formcontainer1"><!-- [et_pb_line_break_holder] --><form accept-charset="UTF-8" action="https://jq191.infusionsoft.com/app/form/process/4e63fef1d0fc54c440bcbc64c38bfa60" class="infusion-form" id="inf_form_4e63fef1d0fc54c440bcbc64c38bfa60" method="POST"><!-- [et_pb_line_break_holder] --> <input name="inf_form_xid" type="hidden" value="4e63fef1d0fc54c440bcbc64c38bfa60" /><!-- [et_pb_line_break_holder] --> <input name="inf_form_name" type="hidden" value="Hormonal Havoc~br~Guide Optin" /><!-- [et_pb_line_break_holder] --> <input name="infusionsoft_version" type="hidden" value="1.69.0.80" /><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <center class="name_div1"><!-- [et_pb_line_break_holder] --> <input class="postinputoptin1 inputoptin1" type="text" style="max-width: 380px!important; width: 100%!important;" id="inf_field_FirstName" name="inf_field_FirstName" placeholder="FIRST NAME" onfocus="this.placeholder=''" onblur="this.placeholder='FIRST NAME'"/><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><br><!-- [et_pb_line_break_holder] --> <input class="postinputoptin1 inputoptin1" style="max-width: 380px!important; width: 100%!important;" id="inf_field_Email" name="inf_field_Email" type="email" placeholder="EMAIL" onfocus="this.placeholder=''" onblur="this.placeholder='EMAIL'"/><!-- [et_pb_line_break_holder] --> </center> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <h3 class="postoptintitle1" style="margin-top: 30px;<!-- [et_pb_line_break_holder] --> margin-bottom: -5px!important;color: #000;font-size: 19px;" align="center">Are you a health professional? *</h3><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <center class="radio_div1"><!-- [et_pb_line_break_holder] --> <br><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <div class="radio-left"><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --><input id="inf_option_Areyouahealthprofessional_864" name="inf_option_Areyouahealthprofessional" type="radio" value="864" /><!-- [et_pb_line_break_holder] --> <label style="margin-left:3px;" for="inf_option_Areyouahealthprofessional_864">Yes</label><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --></div> <!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <div class="radio-right"><!-- [et_pb_line_break_holder] --><input id="inf_option_Areyouahealthprofessional_866" name="inf_option_Areyouahealthprofessional" type="radio" value="866" /><!-- [et_pb_line_break_holder] --> <label style="margin-left:3px;" for="inf_option_Areyouahealthprofessional_866">No</label><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <button class="pageforminputoptin_submit" id="recaptcha_4e63fef1d0fc54c440bcbc64c38bfa60" type="submit">Download My Guide</button><!-- [et_pb_line_break_holder] --> </center> <!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> </form><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] -->