[row]

    [col span__sm="12"]

    [row_inner style="small"]

    [col_inner span__sm="12" padding="24px 0px 14px 16px" align="center" bg_color="#a51717" color="light"]

    Visitation Details

    [/col_inner]

    [/row_inner]
    [row_inner style="small" col_style="divided" v_align="equal"]

    [col_inner span="5" span__sm="12" padding="5px 0px 0px 6px" bg_color="rgb(240, 240, 240)"]

    Preferred Time/Date to Contact

    [/col_inner]
    [col_inner span="7" span__sm="12"]

    [/col_inner]

    [/row_inner]
    [row_inner style="small" col_style="divided" v_align="equal"]

    [col_inner span="5" span__sm="12" padding="5px 0px 0px 6px" bg_color="rgb(240, 240, 240)"]

    Property

    [/col_inner]
    [col_inner span="7" span__sm="12"]

    [/col_inner]

    [/row_inner]
    [row_inner style="small" col_style="divided" v_align="equal"]

    [col_inner span="5" span__sm="12" padding="5px 0px 0px 6px" bg_color="rgb(240, 240, 240)"]

    Type of Property

    [/col_inner]
    [col_inner span="7" span__sm="12"]


    [/col_inner]

    [/row_inner]
    [row_inner style="small" col_style="divided" v_align="equal"]

    [col_inner span="5" span__sm="12" padding="5px 0px 0px 6px" bg_color="rgb(240, 240, 240)"]

    Products

    [/col_inner]
    [col_inner span="7" span__sm="12"]

    * Please Note: Modifications to manufactured bathtubs such as tub cut-outs are unsafe; therefore we do not recommend or complete
    [/col_inner]

    [/row_inner]
    [row_inner style="small" col_style="divided" v_align="equal"]

    [col_inner span="5" span__sm="12" padding="5px 0px 0px 6px" bg_color="rgb(240, 240, 240)"]

    Bathroom Safety Renovations Required

    [/col_inner]
    [col_inner span="7" span__sm="12"]

    [/col_inner]

    [/row_inner]

    [row_inner style="small"]

    [col_inner span__sm="12" padding="24px 0px 14px 16px" align="center" bg_color="#a51717" color="light"]

    Client Information

    [/col_inner]

    [/row_inner]
    [row_inner style="small" col_style="divided" v_align="equal"]

    [col_inner span="5" span__sm="12" padding="5px 0px 0px 6px" bg_color="rgb(240, 240, 240)"]

    Client’s Name *

    [/col_inner]
    [col_inner span="7" span__sm="12"]

    [/col_inner]

    [/row_inner]
    [row_inner style="small" col_style="divided" v_align="equal"]

    [col_inner span="5" span__sm="12" padding="5px 0px 0px 6px" bg_color="rgb(240, 240, 240)"]

    Email Address of Client/Decision Maker/POA’s *

    [/col_inner]
    [col_inner span="7" span__sm="12"]

    [/col_inner]

    [/row_inner]
    [row_inner style="small" col_style="divided" v_align="equal"]

    [col_inner span="5" span__sm="12" padding="5px 0px 0px 6px" bg_color="rgb(240, 240, 240)"]

    Client’s Telephone *

    [/col_inner]
    [col_inner span="7" span__sm="12"]

    [/col_inner]

    [/row_inner]
    [row_inner style="small" col_style="divided" v_align="equal"]

    [col_inner span="5" span__sm="12" padding="5px 0px 0px 6px" bg_color="rgb(240, 240, 240)"]

    Major Intersection Nearby

    [/col_inner]
    [col_inner span="7" span__sm="12"]


    [/col_inner]

    [/row_inner]
    [row_inner style="small" col_style="divided" v_align="equal"]

    [col_inner span="5" span__sm="12" padding="5px 0px 0px 6px" bg_color="rgb(240, 240, 240)"]

    City *

    [/col_inner]
    [col_inner span="7" span__sm="12"]

    [/col_inner]

    [/row_inner]
    [row_inner style="small" col_style="divided" v_align="equal"]

    [col_inner span="5" span__sm="12" padding="5px 0px 0px 6px" bg_color="rgb(240, 240, 240)"]

    Postal Code *

    [/col_inner]
    [col_inner span="7" span__sm="12"]

    [/col_inner]

    [/row_inner]
    [row_inner style="small" col_style="divided" v_align="equal"]

    [col_inner span="5" span__sm="12" padding="5px 0px 0px 6px" bg_color="rgb(240, 240, 240)"]

    Address*

    [/col_inner]
    [col_inner span="7" span__sm="12"]

    [/col_inner]

    [/row_inner]

    [row]

    [col span="6" span__sm="12" span__md="12"]

    [/col]

    [/row]