Drug Mars, LLC. - Reliable Patient Information

Home Products Contact

How can we help your organization?
	Contact Information Drug MARs, LLC. 1233 Silas Deane Highway, 2nd Floor Wethersfield,CT 06109 860-436-5804 info@drugmars.com
<form action="contact2.php" method="POST" id="theform" name="theform" data-validate="parsley"> <table align="center" width="600" cellspacing="10" cellpadding="5" border="0" class="rounded" style="margin:20px;"> <tr> <td colspan="2"><h2>Contact Form</h2></td> </tr> <tr> <td class="formwords"> First Name: </td> <td class="formfields"> <input type="text" name="fname" id="fname" class="formtextfield"></input> </td> </tr> <tr> <td class="formwords"> Last Name: </td> <td class="formfields"> <input type="text" name="lname" id="lname" class="formtextfield"></input> </td> </tr> <tr> <td class="formwords"> Business Name: </td> <td class="formfields"> <input type="text" name="lname" id="bname" class="formtextfield"></input> </td> </tr> <tr> <td class="formwords"> Address: </td> <td class="formfields"> <input type="text" name="lname" id="street" class="formtextfield"></input> </td> </tr> <tr> <td class="formwords"> City: </td> <td class="formfields"> <input type="text" name="lname" id="city" class="formtextfield"></input> </td> </tr> <tr> <td class="formwords"> State: </td> <td class="formfields"> <select name="state"> <option value="AL">AL</option> <option value="AK">AK</option> <option value="AZ">AZ</option> <option value="AR">AR</option> <option value="CA">CA</option> <option value="CO">CO</option> <option value="CT">CT</option> <option value="DE">DE</option> <option value="DC">DC</option> <option value="FL">FL</option> <option value="GA">GA</option> <option value="HI">HI</option> <option value="ID">ID</option> <option value="IL">IL</option> <option value="IN">IN</option> <option value="IA">IA</option> <option value="KS">KS</option> <option value="KY">KY</option> <option value="LA">LA</option> <option value="ME">ME</option> <option value="MD">MD</option> <option value="MA">MA</option> <option value="MI">MI</option> <option value="MN">MN</option> <option value="MS">MS</option> <option value="MO">MO</option> <option value="MT">MT</option> <option value="NE">NE</option> <option value="NV">NV</option> <option value="NH">NH</option> <option value="NJ">NJ</option> <option value="NM">NM</option> <option value="NY">NY</option> <option value="NC">NC</option> <option value="ND">ND</option> <option value="OH">OH</option> <option value="OK">OK</option> <option value="OR">OR</option> <option value="PA">PA</option> <option value="RI">RI</option> <option value="SC">SC</option> <option value="SD">SD</option> <option value="TN">TN</option> <option value="TX">TX</option> <option value="UT">UT</option> <option value="VT">VT</option> <option value="VA">VA</option> <option value="WA">WA</option> <option value="WV">WV</option> <option value="WI">WI</option> <option value="WY">WY</option> </select> </td> </tr> <tr> <td class="formwords"> Zip: </td> <td class="formfields"> <input type="text" name="lname" id="zip" class="formtextfield"></input> </td> </tr> <tr> <td class="formwords"> Email Address(): </td> <td class="formfields"> <input type="text" name="email" id="email" class="formtextfield" data-required="true" data-type="email"></input> </td> </tr> <tr> <td class="formwords"> Phone Number: </td> <td class="formfields"> <input type="text" name="phone" id="phone" class="formtextfield"></input> </td> </tr> <tr> <td class="formwords"> How did you hear about us? </td> <td class="formfields" valign="top"> <select class="formtextfield" name="heard" id="heard"> <option>Select One</option> <option value="">Online</option> <option>By Colleague / Friend</option> <option>Advertising</option> </select> </td> </tr> <tr> <td class="formwords"> Message(): </td> <td class="formfields"> <textarea name="message" class="formtextarea" id="message" rows="8" cols="40" data-required="true" data-notblank="true"></textarea> </td> </tr> <tr> <td> &nbsp </td> <td> <input type="submit" value="Send" style="border:1px solid #f7b334; background-color:white; color:#f7b334; font-family:sans-serif;"></input> </td> </tr> </table> </form>

©Copyright 2014 DrugMARs, LLC. \| 1233 Silas Deane Highway, Wethersfield, CT 06109 \| 860-436-5804