Special Offer Widget

Hello,

I am searching for a wordpress plugin where I can make a widget that is like http://phiredesign.us/wp-content/uploads/2013/01/new-patient-offer.jpg

But I have been unsuccessful finding one. I have found some coupon plugins but they’re not exactly what I’m looking for. I would like to add a form with name, email, phone, message, and code confirmation and expiration date. I am almost certain there is a plugin like this, I am just not searching correctly. Any suggestions would be great. Thanks so much!

Best Regards,

Kelly