Practisonar signup

<div class="aaa_formbuilder_container" style="background-color: #F7F7F7; width: 100%; margin: 0 auto; float: none; "><form method="post" action="" class="aaaformbuilder_form  aaa_formbuilder_form_id_15333" enctype="multipart/form-data"><input type="hidden" name="url" class="get_current_page_url" value=""><input type="hidden" name="container_id" value=""><input type="hidden" name="form_id" value="15333"><input type="hidden" name="form_domain" value="natural-reference.myshopify.com"><input type="hidden" name="" value="Thank You!" class="success_msg"><input type="hidden" name="" value="Please fill all the required fields" class="error_msg"><input type="hidden" name="" value="Please enter a valid email address." class="emailerror_msg"><input type="hidden" name="" value="" class="aaa_thankyoupageurl"><input type="hidden" name="uploadeLimit" class="formUploadLimit" value="10"><input type="hidden" name="allowefiletype" class="allowedfiletype" value=""><input type="hidden" name="conditionallogic" class="conditionallogic" value=""><div class="fb-text form-group field-first-name"><label for="first-name" class="fb-text-label" style="color: rgb(74, 74, 74);">First Name <span class="required">*</span> </label> <input type="text" required="" class="form-control" name="first-name" id="first-name" aria-required="true"></div><div class="fb-text form-group field-last-name"><label for="last-name" class="fb-text-label" style="color: rgb(74, 74, 74);">Last Name <span class="required">*</span> </label> <input type="text" required="" class="form-control" name="last-name" id="last-name" aria-required="true"></div><div class="fb-email form-group field-replyemail"><label for="replyemail" class="fb-email-label" style="color: rgb(74, 74, 74);">Email <span class="required">*</span> </label> <input type="email" required="" class="form-control" name="replyemail" id="replyemail" aria-required="true"></div><div class="fb-password form-group field-customer-password"><label for="customer-password" class="fb-password-label" style="color: rgb(74, 74, 74);">Password <span class="required">*</span> </label> <input type="password" required="" class="form-control" name="customer-password" id="customer-password" aria-required="true"></div><div class="fb-text form-group field-first-1691735843313"><label for="first-1691735843313" class="fb-text-label" style="color: rgb(74, 74, 74);">Enter Your Practisonar Code <span class="required">*</span> </label> <input type="text" required="" class="form-control" name="first-1691735843313" id="first-1691735843313" aria-required="true"></div><div class="fb-submit form-group field-button-1481029333721"><button type="submit" class="button-input btn btn-default" name="button-1481029333721" style="default" id="button-1481029333721">Submit</button></div></form></div><style type="text/css"> .aaaformbuilder_form .fb-submit button { background-color: #00AFEC  !important; } .aaaformbuilder_form .fb-submit button { color: #FFFFFF  !important; } .aaaformbuilder_form .fb-submit button { font-size: 14px !important; }  @media only screen and (max-width: 768px) { .aaa_formbuilder_container { width: 75% !important; } } @media only screen and (max-width: 420px) { .aaa_formbuilder_container { width: 100% !important; } } </style><script> function isMyScriptLoaded() { var url = 'https://shopifycdn.aaawebstore.com/formbuilder/appfiles/aaa_form_builder_script_minify_v1.js?shop=natural-reference.myshopify.com'; var jsFound = 0; var scripts = document.getElementsByTagName('script');  for (var i = scripts.length; i--;) { if (scripts[i].src == url) { jsFound = 1; } } if(!jsFound) { var headTag = document.getElementsByTagName('head')[0]; var jqTag = document.createElement('script'); jqTag.type = 'text/javascript'; jqTag.src = url; jqTag.onload = ''; headTag.appendChild(jqTag); } } isMyScriptLoaded(); </script>