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439668 wordpress page with data capture form

I need a Quote Request Form built for a wordpress page.

Site visitors will request a quote for dental implants.

Form fields:

First Name

Last Name

Primary Phone

Email

Email Confirmed

I want the visitor to indicate which teeth need work done by clicking on the tooth number.

The tooth number should then show in the proper field.

Skills: Anything Goes, HTML, WordPress

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About the Employer:
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Project ID: #2185543