REQUEST A TRIAL

Complete the form and a ResQ representative will contact you to discuss a free trial for your Program or Institution.

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margin:27px 12.5px 0 20px; } #_form_9_ ._form-thank-you { position:relative; left:0; right:0; text-align:center; font-size:18px; } @media all and (min-width:320px) and (max-width:667px) { #_form_9_._inline-form._inline-style ._inline-style._button-wrapper { margin-top:20px !important; margin-left:0 !important; } }</style><form method="POST" action="https://resqmedical.activehosted.com/proc.php" id="_form_9_" class="_form _form_9 _inline-form _dark" novalidate> <input type="hidden" name="u" value="9" /> <input type="hidden" name="f" value="9" /> <input type="hidden" name="s" /> <input type="hidden" name="c" value="0" /> <input type="hidden" name="m" value="0" /> <input type="hidden" name="act" value="sub" /> <input type="hidden" name="v" value="2" /> <div class="_form-content"> <div class="_form_element _x72874349 _full_width _clear" > <div class="_form-title"> Request A Trial </div> </div> <div class="_form_element _x75697205 _full_width _clear" > <div class="_html-code"> <p> Complete the form and a ResQ Medical representative will contact you to discuss a free limited trial for your Program or Institution. </p> </div> </div> <div class="_form_element _field1 _full_width " > <label class="_form-label"> Title </label> <div class="_field-wrapper"> <input type="text" name="field[1]" value="" placeholder="" /> </div> </div> <div class="_form_element _x36801659 _full_width " > <label class="_form-label"> First Name* </label> <div class="_field-wrapper"> <input type="text" name="firstname" placeholder="Type your first name" required/> </div> </div> <div class="_form_element _x21890154 _full_width " > <label class="_form-label"> Last Name* </label> <div class="_field-wrapper"> <input type="text" name="lastname" placeholder="Type your last name" required/> </div> </div> <div class="_form_element _field2 _full_width " > <label class="_form-label"> Suffix </label> <div class="_field-wrapper"> <input type="text" name="field[2]" value="" placeholder="" /> </div> </div> <div class="_form_element _x97631748 _full_width " > <label class="_form-label"> Email* </label> <div class="_field-wrapper"> <input type="text" name="email" placeholder="Type your email" required/> </div> </div> <div class="_form_element _x43973666 _full_width " > <label class="_form-label"> Phone </label> <div class="_field-wrapper"> <input type="text" name="phone" placeholder="Type your phone number" /> </div> </div> <div class="_form_element _field3 _full_width " > <label class="_form-label"> Hospital Name </label> <div class="_field-wrapper"> <input type="text" name="field[3]" value="" placeholder="" /> </div> </div> <div class="_form_element _field4 _full_width " > <label class="_form-label"> Job Title </label> <div class="_row"> <input id="field_4CEO/CMO/CTO" type="radio" name="field[4]" value="CEO/CMO/CTO" > <span> <label for="field_4CEO/CMO/CTO"> CEO/CMO/CTO </span> </div> <div class="_row"> <input id="field_4DIO" type="radio" name="field[4]" value="DIO" > <span> <label for="field_4DIO"> DIO </span> </div> <div class="_row"> <input id="field_4Program Director" type="radio" name="field[4]" value="Program Director" > <span> <label for="field_4Program Director"> Program Director </span> </div> <div class="_row"> <input id="field_4Program Coordinator" type="radio" name="field[4]" value="Program Coordinator" > <span> <label for="field_4Program Coordinator"> Program Coordinator </span> </div> <div class="_row"> <input id="field_4GME Staff" type="radio" name="field[4]" value="GME Staff" > <span> <label for="field_4GME Staff"> GME Staff </span> </div> <div class="_row"> <input id="field_4Resident" type="radio" name="field[4]" value="Resident" > <span> <label for="field_4Resident"> Resident </span> </div> <div class="_row"> <input id="field_4Other" type="radio" name="field[4]" value="Other" checked > <span> <label for="field_4Other"> Other </span> </div> </div> <div class="_form_element _field5 _full_width " > <label class="_form-label"> If "Other" please enter your job title. </label> <div class="_field-wrapper"> <input type="text" name="field[5]" value="" placeholder="" /> </div> </div> <div class="_button-wrapper _full_width"> <button id="_form_9_submit" class="_submit" type="submit"> Submit </button> </div> <div class="_clear-element"> </div> </div> <div class="_form-thank-you" style="display:none;"> </div> </form><script type="text/javascript">window._show_thank_you = function(id, message, trackcmp_url) { var form = document.getElementById('_form_' + id + '_'), thank_you = form.querySelector('._form-thank-you'); 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