<h2 style="margin:35px 0 10px 0">Bel mij terug</h2>
<form id="belMeTerug">
    <input id="belNaam" type="text" value="Naam" />
    <input id="belNummer" type="text" value="Telefoonnummer" />
    <input id="paginaURL" type="hidden" value="<?php echo($_SERVER['REQUEST_URI']); ?>" />
</form>
<div id="belMeTerugReplacement"><p>Succesvol verzonden.</p></div>
<a onClick="_gaq.push(['_trackEvent', 'formulier', 'verstuur', 'bel-mij-terug']);" id="belMeTerugSubmit" class="actionBtn knopMedium"><span class="text">verzenden</span><span class="up"></span><span class="hover"></span><span class="upRight"></span><span class="hoverRight"></span></a>