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                        $<span class="js_price_container" content="149.99" data-price="149.99" data-id="64528">149.99</span>
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                        $<span class="js_price_container" content="169.99" data-price="169.99" data-id="102579">169.99</span>
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                <a href="https://dental.draft.webcart.us/build-it-fr-pentron-dental-core-build-up.htm" title=" Build-It FR Fiber Reinforced Core Material 25 ml Cartridge (Pentron)">
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                        $<span class="js_price_container" content="182.99" data-price="182.99" data-id="115997">182.99</span>
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                <a href="https://dental.draft.webcart.us/cervitec-plus-single-dose-refill-20.htm" title=" Cervitec Plus Chlorhexidine Varnish 20/pk (Ivoclar)">
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		     <input type="text" value="" name="DATA[LNAME]" size="45" maxlength="255" dir="ltr" id="ASK_LNAME" class=" mandatory form-control" >
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<input type="hidden" name="BUFFER" value="CONTACT_US">
<input type="hidden" name="section" value="contact_form">
<input type="hidden" name="TAG" value="CONTACT5">
<input type="hidden" name="ac" value="insert">
<input type="hidden" name="next_action" value="default">
<input type="hidden" name="next_section" value="contact_us_thanks">
<input type="hidden" name="onerror_section" value="products">


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                        <form action="https://dental.draft.webcart.us/index.php" method="post" name="login_form" id="main_login_form" class="">
                            <span class="hidden ajax_next_url"><!--replace this comment with URL--></span>
                            <DIV class="text-center form_err_message error_mess"><br>
                                <span class="form_email_error error_mess">Value entered for e-mail is invalid<br></span>
                                <span class="form_password_error error_mess">Passwords don't match<br></span>
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                            <div class="login_form">
                                <div class="form-group row email">
                                    <label class="col-3 col-form-label">E-mail:<b class="madatorystar">*</b></label>
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                                        <input type="text" value="" name="DATA[EMAIL]" size="35" maxlength="255" dir="ltr" id="LOGIN_EMAIL" placeholder="Enter your e-mail used as login" class=" mandatory email form-control form-control-sm" >
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                                    <label class="col-3 col-form-label">Password:<b class="madatorystar">*</b></label>
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                                        <input type="password" value="" name="DATA[PASSWORD1]" size="35" maxlength="255" dir="ltr" id="LOGIN_PASSWORD1" placeholder="Enter your account password" class=" mandatory form-control form-control-sm" >
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                            <input type=hidden name="ACC_TPY" value="CUSTOMERS">
                            <input type=hidden name="DATA[ACC_TPY]" value="CUSTOMERS">

                            <input type="hidden" name="section" value="forgot_pass">
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<div id="mm-quote" class="modal fade" tabindex="-1" aria-labelledby="mm-quoteLabel" aria-hidden="true">
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		<div class="modal-content">

			 <div class="modal-header">
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	<form action="index.php" method="post" name="contact_form" class="contact_form" data-json="1">

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						<DIV class="form_err_message text-center alert alert-danger">
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						  <div class="row form-group mb-3">
							<label class="col-md-4 col-form-label text-md-end">Full Name: <b class="madatorystar">*</b></label>
							 <div class="col-md-8">
							  <input type="text" value="" name="DATA[LNAME]" size="45" maxlength="255" dir="ltr" id="CONTACT10_LNAME" class=" form-control mandatory" >
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							<label class="col-md-4 col-form-label text-md-end">Company:</label>
							 <div class="col-md-8">
							  <input type="text" value="" name="DATA[COMPANY]" size="45" maxlength="255" dir="ltr" id="CONTACT10_COMPANY" class=" form-control mandatory" >
							</div>
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						  <div class="row form-group mb-3">
							<label class="col-md-4 col-form-label text-md-end">E-mail: <b class="madatorystar">*</b></label>
							 <div class="col-md-8">
							  <input type="text" value="" name="DATA[EMAIL]" size="45" maxlength="255" dir="ltr" id="CONTACT10_EMAIL" class=" form-control mandatory mail" >
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							  <input type="text" value="" name="DATA[PHONE]" size="45" maxlength="255" dir="ltr" id="CONTACT10_PHONE" class=" form-control" >
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       		 <input type="submit" name="submit" value=" Send " class="btn btn-primary">	

			
					<input type="hidden" name="BUFFER" value="CONTACT_US">
					<input type="hidden" name="section" value="contact_form">
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<div class="modal fade" id="QUOTEModal" tabindex="-1" role="dialog" aria-labelledby="QUOTEModalLabel">
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<form action="index.php" method="post" name="contact_form" class="form-horizontal contact_form" data-ga-event-category="contact_form" data-ga-event-action="submit" data-ga-event-label="CONTACT3">
<div align="center" class="error_mess ajax_errors" style="display:none"></div>
<DIV class="form_err_message error_mess" align="center">
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</DIV>


	<div class="form-group row">
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	    <div class="col-sm-8">
	      <input type="text" value="" name="DATA[FNAME]" size="45" maxlength="255" dir="ltr" id="CONTACT_FNAME" class=" mandatory form-control" >
	    </div>
  	</div>
  	<div class="form-group row">
	    <label class="col-sm-4 control-label">Last Name<b class="madatorystar">*</b></label>
	    <div class="col-sm-8">
	      <input type="text" value="" name="DATA[LNAME]" size="45" maxlength="255" dir="ltr" id="CONTACT_LNAME" class=" mandatory form-control" >
	    </div>
  	</div>
	<div class="form-group row">
	    <label class="col-sm-4 control-label">E-mail<b class="madatorystar">*</b></label>
	    <div class="col-sm-8">
	      <input type="text" value="" name="DATA[EMAIL]" size="45" maxlength="255" dir="ltr" id="CONTACT_EMAIL" class=" mandatory form-control" >
	    </div>
  	</div>
	<div class="form-group row">
	    <label class="col-sm-4 control-label">Phone</label>
	    <div class="col-sm-8">
	     <input type="text" value="" name="DATA[PHONE]" size="45" maxlength="255" dir="ltr" id="CONTACT_PHONE" class=" form-control" >
	    </div>
  	</div>
  	
	<div class="form-group row">
	    <label class="col-sm-4 control-label">Ship to Country<b class="madatorystar">*</b></label>
	    <div class="col-sm-8">
	   	<select size="1" id="CONTACT_COUNTRY" name="DATA[COUNTRY]" dir="ltr" class=" mandatory form-control form-select" ><option value="USA" class=" " >UNITED STATES</option><option value="CA" class=" " >CANADA</option><option value="MX" class=" " >MEXICO</option></select>
	    </div>
  	</div>
  	<div class="form-group row">
	    <label class="col-sm-4 control-label">System you are interested in</label>
	    <div class="col-sm-8">
	   <textarea cols="30" rows="2" id="CONTACT_SYSTEM" name="DATA[SYSTEM]" dir="ltr" class=" form-control" ></textarea>
	    </div>
  	</div>
  	

	<div class="form-group row">
	    <label class="col-sm-4 control-label">Comments</label>
	    <div class="col-sm-8">
	   <textarea cols="30" rows="2" id="CONTACT_COMMENTS" name="DATA[COMMENTS]" dir="ltr" class=" form-control" ></textarea>
	    </div>
  	</div>


      </div>
      <div class="modal-footer">
        <button type="button" class="btn btn-secondary" data-dismiss="modal">Close</button>
        <input type="hidden" name="DATA[SKU]" value="">
		<input type="hidden" name="DATA[PRODUCT_NAME]" value="">
		<input type="hidden" name="DATA[LINK]" value="https://dental.draft.webcart.us/products/">
		<input type="submit" name="submit" value="Request a Quote" class="btn btn-primary">

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<input type="hidden" name="BUFFER" value="CONTACT_US">
<input type="hidden" name="section" value="contact_form">
<input type="hidden" name="userid" value="">
<input type="hidden" name="TAG" value="CONTACT3">
<input type="hidden" name="ac" value="insert">
<input type="hidden" name="next_action" value="default">
<input type="hidden" name="next_section" value="contact_us_thanks">
<input type="hidden" name="onerror_section" value="products">
<input type="hidden" name="DATA[THE_TIME]" value="NOW()">


</FORM>

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</div>


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