[wpforms id="21910" title="false"]
<div class="wpforms-container wpforms-container-full" id="wpforms-21910"><form id="wpforms-form-21910" class="wpforms-validate wpforms-form wpforms-ajax-form" data-formid="21910" method="post" enctype="multipart/form-data" action="/product-category/microincision/vitreoretinal-2/" data-token="0acd8cf92743685a382a5bc12022f679"><noscript class="wpforms-error-noscript">Please enable JavaScript in your browser to complete this form.</noscript><div class="wpforms-page-indicator progress" data-indicator="progress" data-indicator-color="#445899" data-scroll="1"><span class="wpforms-page-indicator-page-title" ></span><span class="wpforms-page-indicator-page-title-sep" style="display:none;"> - </span><span class="wpforms-page-indicator-steps">Step <span class="wpforms-page-indicator-steps-current">1</span> of 6</span><div class="wpforms-page-indicator-page-progress-wrap"><div class="wpforms-page-indicator-page-progress" style="width:16.666666666667%;background-color:#445899;"></div></div></div><div class="wpforms-field-container"><div class="wpforms-page wpforms-page-1 prog-bar"><div id="wpforms-21910-field_11-container" class="wpforms-field wpforms-field-pagebreak prog-bar" data-field-id="11"></div><div id="wpforms-21910-field_6-container" class="wpforms-field wpforms-field-select wpforms-field-select-style-classic" data-field-id="6"><label class="wpforms-field-label" for="wpforms-21910-field_6">Country of Residence <span class="wpforms-required-label">*</span></label><select id="wpforms-21910-field_6" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][6]" required="required"><option value="Afghanistan" >Afghanistan</option><option value="Albania" >Albania</option><option value="Algeria" >Algeria</option><option value="American Samoa" >American Samoa</option><option value="Andorra" >Andorra</option><option value="Angola" >Angola</option><option value="Anguilla" >Anguilla</option><option value="Antarctica" >Antarctica</option><option value="Antigua and Barbuda" >Antigua and Barbuda</option><option value="Argentina" >Argentina</option><option value="Armenia" >Armenia</option><option value="Aruba" >Aruba</option><option value="Australia" >Australia</option><option value="Austria" >Austria</option><option value="Azerbaijan" >Azerbaijan</option><option value="Bahamas" >Bahamas</option><option value="Bahrain" >Bahrain</option><option value="Bangladesh" >Bangladesh</option><option value="Barbados" >Barbados</option><option value="Belarus" >Belarus</option><option value="Belgium" >Belgium</option><option value="Belize" >Belize</option><option value="Benin" >Benin</option><option value="Bermuda" >Bermuda</option><option value="Bhutan" >Bhutan</option><option value="Bolivia (Plurinational State of)" >Bolivia (Plurinational State of)</option><option value="Bosnia and Herzegovina" >Bosnia and Herzegovina</option><option value="Botswana" >Botswana</option><option value="Bouvet Island" >Bouvet Island</option><option value="Brazil" >Brazil</option><option value="British Indian Ocean Territory" >British Indian Ocean Territory</option><option value="Brunei Darussalam" >Brunei Darussalam</option><option value="Bulgaria" >Bulgaria</option><option value="Burkina Faso" >Burkina Faso</option><option value="Burundi" >Burundi</option><option value="Cabo Verde" >Cabo Verde</option><option value="Cambodia" >Cambodia</option><option value="Cameroon" >Cameroon</option><option value="Canada" >Canada</option><option value="Cayman Islands" >Cayman Islands</option><option value="Central African Republic" >Central African Republic</option><option value="Chad" >Chad</option><option value="Chile" >Chile</option><option value="China" >China</option><option value="Christmas Island" >Christmas Island</option><option value="Cocos (Keeling) Islands" >Cocos (Keeling) Islands</option><option value="Colombia" >Colombia</option><option value="Comoros" >Comoros</option><option value="Congo" >Congo</option><option value="Congo (Democratic Republic of the)" >Congo (Democratic Republic of the)</option><option value="Cook Islands" >Cook Islands</option><option value="Costa Rica" >Costa Rica</option><option value="Croatia" >Croatia</option><option value="Cuba" >Cuba</option><option value="Curaçao" >Curaçao</option><option value="Cyprus" >Cyprus</option><option value="Czech Republic" >Czech Republic</option><option value="Côte d'Ivoire" >Côte d'Ivoire</option><option value="Denmark" >Denmark</option><option value="Djibouti" >Djibouti</option><option value="Dominica" >Dominica</option><option value="Dominican Republic" >Dominican Republic</option><option value="Ecuador" >Ecuador</option><option value="Egypt" >Egypt</option><option value="El Salvador" >El Salvador</option><option value="Equatorial Guinea" >Equatorial Guinea</option><option value="Eritrea" >Eritrea</option><option value="Estonia" >Estonia</option><option value="Eswatini (Kingdom of)" >Eswatini (Kingdom of)</option><option value="Ethiopia" >Ethiopia</option><option value="Falkland Islands (Malvinas)" >Falkland Islands (Malvinas)</option><option value="Faroe Islands" >Faroe Islands</option><option value="Fiji" >Fiji</option><option value="Finland" >Finland</option><option value="France" >France</option><option value="French Guiana" >French Guiana</option><option value="French Polynesia" >French Polynesia</option><option value="French Southern Territories" >French Southern Territories</option><option value="Gabon" >Gabon</option><option value="Gambia" >Gambia</option><option value="Georgia" >Georgia</option><option value="Germany" >Germany</option><option value="Ghana" >Ghana</option><option value="Gibraltar" >Gibraltar</option><option value="Greece" >Greece</option><option value="Greenland" >Greenland</option><option value="Grenada" >Grenada</option><option value="Guadeloupe" >Guadeloupe</option><option value="Guam" >Guam</option><option value="Guatemala" >Guatemala</option><option value="Guernsey" >Guernsey</option><option value="Guinea" >Guinea</option><option value="Guinea-Bissau" >Guinea-Bissau</option><option value="Guyana" >Guyana</option><option value="Haiti" >Haiti</option><option value="Heard Island and McDonald Islands" >Heard Island and McDonald Islands</option><option value="Honduras" >Honduras</option><option value="Hong Kong" >Hong Kong</option><option value="Hungary" >Hungary</option><option value="Iceland" >Iceland</option><option value="India" >India</option><option value="Indonesia" >Indonesia</option><option value="Iran (Islamic Republic of)" >Iran (Islamic Republic of)</option><option value="Iraq" >Iraq</option><option value="Ireland (Republic of)" >Ireland (Republic of)</option><option value="Isle of Man" >Isle of Man</option><option value="Israel" >Israel</option><option value="Italy" >Italy</option><option value="Jamaica" >Jamaica</option><option value="Japan" >Japan</option><option value="Jersey" >Jersey</option><option value="Jordan" >Jordan</option><option value="Kazakhstan" >Kazakhstan</option><option value="Kenya" >Kenya</option><option value="Kiribati" >Kiribati</option><option value="Korea (Democratic People's Republic of)" >Korea (Democratic People's Republic of)</option><option value="Korea (Republic of)" >Korea (Republic of)</option><option value="Kosovo" >Kosovo</option><option value="Kuwait" >Kuwait</option><option value="Kyrgyzstan" >Kyrgyzstan</option><option value="Lao People's Democratic Republic" >Lao People's Democratic Republic</option><option value="Latvia" >Latvia</option><option value="Lebanon" >Lebanon</option><option value="Lesotho" >Lesotho</option><option value="Liberia" >Liberia</option><option value="Libya" >Libya</option><option value="Liechtenstein" >Liechtenstein</option><option value="Lithuania" >Lithuania</option><option value="Luxembourg" >Luxembourg</option><option value="Macao" >Macao</option><option value="Madagascar" >Madagascar</option><option value="Malawi" >Malawi</option><option value="Malaysia" >Malaysia</option><option value="Maldives" >Maldives</option><option value="Mali" >Mali</option><option value="Malta" >Malta</option><option value="Marshall Islands" >Marshall Islands</option><option value="Martinique" >Martinique</option><option value="Mauritania" >Mauritania</option><option value="Mauritius" >Mauritius</option><option value="Mayotte" >Mayotte</option><option value="Mexico" >Mexico</option><option value="Micronesia (Federated States of)" >Micronesia (Federated States of)</option><option value="Moldova (Republic of)" >Moldova (Republic of)</option><option value="Monaco" >Monaco</option><option value="Mongolia" >Mongolia</option><option value="Montenegro" >Montenegro</option><option value="Montserrat" >Montserrat</option><option value="Morocco" >Morocco</option><option value="Mozambique" >Mozambique</option><option value="Myanmar" >Myanmar</option><option value="Namibia" >Namibia</option><option value="Nauru" >Nauru</option><option value="Nepal" >Nepal</option><option value="Netherlands" >Netherlands</option><option value="New Caledonia" >New Caledonia</option><option value="New Zealand" >New Zealand</option><option value="Nicaragua" >Nicaragua</option><option value="Niger" >Niger</option><option value="Nigeria" >Nigeria</option><option value="Niue" >Niue</option><option value="Norfolk Island" >Norfolk Island</option><option value="North Macedonia (Republic of)" >North Macedonia (Republic of)</option><option value="Northern Mariana Islands" >Northern Mariana Islands</option><option value="Norway" >Norway</option><option value="Oman" >Oman</option><option value="Pakistan" >Pakistan</option><option value="Palau" >Palau</option><option value="Palestine (State of)" >Palestine (State of)</option><option value="Panama" >Panama</option><option value="Papua New Guinea" >Papua New Guinea</option><option value="Paraguay" >Paraguay</option><option value="Peru" >Peru</option><option value="Philippines" >Philippines</option><option value="Pitcairn" >Pitcairn</option><option value="Poland" >Poland</option><option value="Portugal" >Portugal</option><option value="Puerto Rico" >Puerto Rico</option><option value="Qatar" >Qatar</option><option value="Romania" >Romania</option><option value="Russian Federation" >Russian Federation</option><option value="Rwanda" >Rwanda</option><option value="Réunion" >Réunion</option><option value="Saint Barthélemy" >Saint Barthélemy</option><option value="Saint Helena, Ascension and Tristan da Cunha" >Saint Helena, Ascension and Tristan da Cunha</option><option value="Saint Kitts and Nevis" >Saint Kitts and Nevis</option><option value="Saint Lucia" >Saint Lucia</option><option value="Saint Martin (French part)" >Saint Martin (French part)</option><option value="Saint Pierre and Miquelon" >Saint Pierre and Miquelon</option><option value="Saint Vincent and the Grenadines" >Saint Vincent and the Grenadines</option><option value="Samoa" >Samoa</option><option value="San Marino" >San Marino</option><option value="Sao Tome and Principe" >Sao Tome and Principe</option><option value="Saudi Arabia" >Saudi Arabia</option><option value="Senegal" >Senegal</option><option value="Serbia" >Serbia</option><option value="Seychelles" >Seychelles</option><option value="Sierra Leone" >Sierra Leone</option><option value="Singapore" >Singapore</option><option value="Sint Maarten (Dutch part)" >Sint Maarten (Dutch part)</option><option value="Slovakia" >Slovakia</option><option value="Slovenia" >Slovenia</option><option value="Solomon Islands" >Solomon Islands</option><option value="Somalia" >Somalia</option><option value="South Africa" >South Africa</option><option value="South Georgia and the South Sandwich Islands" >South Georgia and the South Sandwich Islands</option><option value="South Sudan" >South Sudan</option><option value="Spain" >Spain</option><option value="Sri Lanka" >Sri Lanka</option><option value="Sudan" >Sudan</option><option value="Suriname" >Suriname</option><option value="Svalbard and Jan Mayen" >Svalbard and Jan Mayen</option><option value="Sweden" >Sweden</option><option value="Switzerland" >Switzerland</option><option value="Syrian Arab Republic" >Syrian Arab Republic</option><option value="Taiwan, Province of China" >Taiwan, Province of China</option><option value="Tajikistan" >Tajikistan</option><option value="Tanzania (United Republic of)" >Tanzania (United Republic of)</option><option value="Thailand" >Thailand</option><option value="Timor-Leste" >Timor-Leste</option><option value="Togo" >Togo</option><option value="Tokelau" >Tokelau</option><option value="Tonga" >Tonga</option><option value="Trinidad and Tobago" >Trinidad and Tobago</option><option value="Tunisia" >Tunisia</option><option value="Turkey" >Turkey</option><option value="Turkmenistan" >Turkmenistan</option><option value="Turks and Caicos Islands" >Turks and Caicos Islands</option><option value="Tuvalu" >Tuvalu</option><option value="Uganda" >Uganda</option><option value="Ukraine" >Ukraine</option><option value="United Arab Emirates" >United Arab Emirates</option><option value="United Kingdom of Great Britain and Northern Ireland" >United Kingdom of Great Britain and Northern Ireland</option><option value="United States Minor Outlying Islands" >United States Minor Outlying Islands</option><option value="United States of America" >United States of America</option><option value="Uruguay" >Uruguay</option><option value="Uzbekistan" >Uzbekistan</option><option value="Vanuatu" >Vanuatu</option><option value="Vatican City State" >Vatican City State</option><option value="Venezuela (Bolivarian Republic of)" >Venezuela (Bolivarian Republic of)</option><option value="Vietnam" >Vietnam</option><option value="Virgin Islands (British)" >Virgin Islands (British)</option><option value="Virgin Islands (U.S.)" >Virgin Islands (U.S.)</option><option value="Wallis and Futuna" >Wallis and Futuna</option><option value="Western Sahara" >Western Sahara</option><option value="Yemen" >Yemen</option><option value="Zambia" >Zambia</option><option value="Zimbabwe" >Zimbabwe</option><option value="Åland Islands" >Åland Islands</option></select></div><div id="wpforms-21910-field_10-container" class="wpforms-field wpforms-field-pagebreak" data-field-id="10"><div class="wpforms-clear wpforms-pagebreak-left"><button class="wpforms-page-button wpforms-page-next" data-action="next" data-page="1" data-formid="21910" disabled>Next</button></div></div></div><div class="wpforms-page wpforms-page-2 " style="display:none;"><div id="wpforms-21910-field_13-container" class="wpforms-field wpforms-field-radio" data-field-id="13"><label class="wpforms-field-label" for="wpforms-21910-field_13">Are you a new or returning customer?</label><ul id="wpforms-21910-field_13"><li class="choice-1 depth-1"><input type="radio" id="wpforms-21910-field_13_1" name="wpforms[fields][13]" value="New Customer" ><label class="wpforms-field-label-inline" for="wpforms-21910-field_13_1">New Customer</label></li><li class="choice-2 depth-1"><input type="radio" id="wpforms-21910-field_13_2" name="wpforms[fields][13]" value="Returning Customer" ><label class="wpforms-field-label-inline" for="wpforms-21910-field_13_2">Returning Customer</label></li></ul></div><div id="wpforms-21910-field_15-container" class="wpforms-field wpforms-field-pagebreak" data-field-id="15"><div class="wpforms-clear wpforms-pagebreak-left"><button class="wpforms-page-button wpforms-page-prev" data-action="prev" data-page="2" data-formid="21910" disabled>Previous</button><button class="wpforms-page-button wpforms-page-next" data-action="next" data-page="2" data-formid="21910" disabled>Next</button></div></div></div><div class="wpforms-page wpforms-page-3 " style="display:none;"><div id="wpforms-21910-field_21-container" class="wpforms-field wpforms-field-checkbox wpforms-conditional-trigger" data-field-id="21"><label class="wpforms-field-label" for="wpforms-21910-field_21">How did you hear about us?</label><ul id="wpforms-21910-field_21"><li class="choice-1 depth-1"><input type="checkbox" id="wpforms-21910-field_21_1" name="wpforms[fields][21][]" value="Internet Search" ><label class="wpforms-field-label-inline" for="wpforms-21910-field_21_1">Internet Search</label></li><li class="choice-2 depth-1"><input type="checkbox" id="wpforms-21910-field_21_2" name="wpforms[fields][21][]" value="Exhibitions / Meetings" ><label class="wpforms-field-label-inline" for="wpforms-21910-field_21_2">Exhibitions / Meetings</label></li><li class="choice-3 depth-1"><input type="checkbox" id="wpforms-21910-field_21_3" name="wpforms[fields][21][]" value="Local Distributor" ><label class="wpforms-field-label-inline" for="wpforms-21910-field_21_3">Local Distributor</label></li><li class="choice-5 depth-1"><input type="checkbox" id="wpforms-21910-field_21_5" name="wpforms[fields][21][]" value="Recommendation" ><label class="wpforms-field-label-inline" for="wpforms-21910-field_21_5">Recommendation</label></li><li class="choice-4 depth-1"><input type="checkbox" id="wpforms-21910-field_21_4" name="wpforms[fields][21][]" value="Magazine / Online Adverts" ><label class="wpforms-field-label-inline" for="wpforms-21910-field_21_4">Magazine / Online Adverts</label></li><li class="choice-6 depth-1"><input type="checkbox" id="wpforms-21910-field_21_6" name="wpforms[fields][21][]" value="Other" ><label class="wpforms-field-label-inline" for="wpforms-21910-field_21_6">Other</label></li></ul></div><div id="wpforms-21910-field_22-container" class="wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show" data-field-id="22" style="display:none;"><label class="wpforms-field-label" for="wpforms-21910-field_22">Exhibitions/Meeting Details:</label><textarea id="wpforms-21910-field_22" class="wpforms-field-medium" name="wpforms[fields][22]" ></textarea></div><div id="wpforms-21910-field_23-container" class="wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show" data-field-id="23" style="display:none;"><label class="wpforms-field-label" for="wpforms-21910-field_23">Distributor Details:</label><textarea id="wpforms-21910-field_23" class="wpforms-field-medium" name="wpforms[fields][23]" ></textarea></div><div id="wpforms-21910-field_24-container" class="wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show" data-field-id="24" style="display:none;"><label class="wpforms-field-label" for="wpforms-21910-field_24">Details:</label><textarea id="wpforms-21910-field_24" class="wpforms-field-medium" name="wpforms[fields][24]" ></textarea></div><div id="wpforms-21910-field_25-container" class="wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show" data-field-id="25" style="display:none;"><label class="wpforms-field-label" for="wpforms-21910-field_25">Publication or Website:</label><textarea id="wpforms-21910-field_25" class="wpforms-field-medium" name="wpforms[fields][25]" ></textarea></div><div id="wpforms-21910-field_26-container" class="wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show" data-field-id="26" style="display:none;"><label class="wpforms-field-label" for="wpforms-21910-field_26">Details:</label><textarea id="wpforms-21910-field_26" class="wpforms-field-medium" name="wpforms[fields][26]" ></textarea></div><div id="wpforms-21910-field_16-container" class="wpforms-field wpforms-field-pagebreak" data-field-id="16"><div class="wpforms-clear wpforms-pagebreak-left"><button class="wpforms-page-button wpforms-page-prev" data-action="prev" data-page="3" data-formid="21910" disabled>Previous</button><button class="wpforms-page-button wpforms-page-next" data-action="next" data-page="3" data-formid="21910" disabled>Next</button></div></div></div><div class="wpforms-page wpforms-page-4 " style="display:none;"><div id="wpforms-21910-field_27-container" class="wpforms-field wpforms-field-checkbox wpforms-conditional-trigger" data-field-id="27"><label class="wpforms-field-label" for="wpforms-21910-field_27">Did you find what you were looking for?</label><ul id="wpforms-21910-field_27"><li class="choice-1 depth-1"><input type="checkbox" id="wpforms-21910-field_27_1" name="wpforms[fields][27][]" value="Yes" ><label class="wpforms-field-label-inline" for="wpforms-21910-field_27_1">Yes</label></li><li class="choice-2 depth-1"><input type="checkbox" id="wpforms-21910-field_27_2" name="wpforms[fields][27][]" value="No" ><label class="wpforms-field-label-inline" for="wpforms-21910-field_27_2">No</label></li></ul></div><div id="wpforms-21910-field_28-container" class="wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show" data-field-id="28" style="display:none;"><label class="wpforms-field-label" for="wpforms-21910-field_28">Please explain or state the device/instrument you were looking for?</label><textarea id="wpforms-21910-field_28" class="wpforms-field-medium" name="wpforms[fields][28]" ></textarea></div><div id="wpforms-21910-field_29-container" class="wpforms-field wpforms-field-pagebreak" data-field-id="29"><div class="wpforms-clear wpforms-pagebreak-left"><button class="wpforms-page-button wpforms-page-prev" data-action="prev" data-page="4" data-formid="21910" disabled>Previous</button><button class="wpforms-page-button wpforms-page-next" data-action="next" data-page="4" data-formid="21910" disabled>Next</button></div></div></div><div class="wpforms-page wpforms-page-5 " style="display:none;"><div id="wpforms-21910-field_30-container" class="wpforms-field wpforms-field-checkbox wpforms-conditional-trigger" data-field-id="30"><label class="wpforms-field-label" for="wpforms-21910-field_30">How likely are you to recommend Duckworth & Kent devices/instruments?</label><ul id="wpforms-21910-field_30"><li class="choice-1 depth-1"><input type="checkbox" id="wpforms-21910-field_30_1" name="wpforms[fields][30][]" value="Very Likely" ><label class="wpforms-field-label-inline" for="wpforms-21910-field_30_1">Very Likely</label></li><li class="choice-2 depth-1"><input type="checkbox" id="wpforms-21910-field_30_2" name="wpforms[fields][30][]" value="Likely" ><label class="wpforms-field-label-inline" for="wpforms-21910-field_30_2">Likely</label></li><li class="choice-3 depth-1"><input type="checkbox" id="wpforms-21910-field_30_3" name="wpforms[fields][30][]" value="Unlikely" ><label class="wpforms-field-label-inline" for="wpforms-21910-field_30_3">Unlikely</label></li></ul></div><div id="wpforms-21910-field_31-container" class="wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show" data-field-id="31" style="display:none;"><label class="wpforms-field-label" for="wpforms-21910-field_31">If not at all, please explain why?</label><textarea id="wpforms-21910-field_31" class="wpforms-field-medium" name="wpforms[fields][31]" ></textarea></div><div id="wpforms-21910-field_32-container" class="wpforms-field wpforms-field-pagebreak" data-field-id="32"><div class="wpforms-clear wpforms-pagebreak-left"><button class="wpforms-page-button wpforms-page-prev" data-action="prev" data-page="5" data-formid="21910" disabled>Previous</button><button class="wpforms-page-button wpforms-page-next" data-action="next" data-page="5" data-formid="21910" disabled>Next</button></div></div></div><div class="wpforms-page wpforms-page-6 last " style="display:none;"><div id="wpforms-21910-field_33-container" class="wpforms-field wpforms-field-textarea" data-field-id="33"><label class="wpforms-field-label" for="wpforms-21910-field_33">Any other comments?</label><textarea id="wpforms-21910-field_33" class="wpforms-field-medium" name="wpforms[fields][33]" ></textarea></div><div id="wpforms-21910-field_12-container" class="wpforms-field wpforms-field-pagebreak" data-field-id="12"><div class="wpforms-clear wpforms-pagebreak-left"><button class="wpforms-page-button wpforms-page-prev" data-action="prev" data-page="6" data-formid="21910" disabled>Previous</button></div></div></div></div><div class="wpforms-submit-container" style="display:none;"><input type="hidden" name="wpforms[id]" value="21910"><input type="hidden" name="wpforms[author]" value="2"><button type="submit" name="wpforms[submit]" class="wpforms-submit " id="wpforms-submit-21910" value="wpforms-submit" aria-live="assertive" data-alt-text="Sending..." data-submit-text="Submit">Submit</button><img src="https://duckworth-and-kent.com/wp-content/plugins/wpforms/assets/images/submit-spin.svg" class="wpforms-submit-spinner" style="display: none;" width="26" height="26" alt=""></div></form></div> <!-- .wpforms-container -->
