Simple Php/html Form

Simple Php/html Form
We require a simple contact form for a website (14 fields)




House Number:


Contact Telephone Number:*

Date of Birth:*

Year of Accident:*

Accident Type:*

Call me back:* at

Also to include following fields:
Brief Description of Accident & Circumstances: (Large text box)
How did you find us? (Drop down with following options:
• Word of mouth
• Leaflet
• Business card
• Poster
• Web Search
• Forum
• Local News Paper
• TV/ Radio

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