Wordpress plugin - disclaimer

I requite a plugin that can enable on a page-by-page basis whether to display a disclaimer. The disclaimer also has one input that needs to be validated (but not stored).

- Hit a protected page and the user is confronted with a form
- The form asks:
-- Which country are you from? (Dropdown list)
-- What is your country dial code (text entry)
The country code would get validated to see if they are telling the truth

They cannot proceed if the country code is not valid.

If the country code is valid they can proceed and see the full disclaimer text and must agree to it.

However, if they are from one of five specific countries we tell them they are not allowed in.