document.write('<style type="text/css">.form_table {background-color:#ffffff;}.label {border: solid 1px #ffffff;font-family:Arial;color:#000000;font-size:12px;}.input {border: solid 1px #ccc;background-color:#ffffff;font-family:Arial;color:#000000;font-size:12px;}</style><script language="javascript">function check_field_1666() {var a_field_ids = new Array(\'field_9171\',\'field_9172\',\'field_9173\',\'field_9174\',\'field_9175\',\'field_9176\',\'field_9177\',\'captcha_1666\');var a_field_labels = new Array(\'First Name\',\'Last Name\',\'Email\',\'Contact Phone Number\',\'City\',\'State\',\'Are you currently experiencing symptoms or pain?\',\'Security code\');for(var i=0; i<a_field_ids.length; i++) {if( document.getElementById(a_field_ids[i]).value == \'\') {alert(\'Please fill the following field :\'+a_field_labels[i]);return false;}}var a_email_field_ids = new Array();var a_email_field_labels = new Array();for(var i=0; i<a_email_field_ids.length; i++) {if (document.getElementById(a_email_field_ids[i]).value.search(/^.+@.+\..+$/)) {alert(\'Please enter a valid email address in the field : \'+a_email_field_labels[i]);return false;}}return true;}</script><form method="post" action="http://www.steeljaws.com/soap.php?todo=form_submit&form_id=1666" onSubmit="return(check_field_1666());" ><input type="hidden" name="formsubmit" value="1"><input type="hidden" name="form_url" value=""><table class="form_table"><tr><td colspan="2">Please fill out the following form to receive a complimentary consultation.<br/><br/></td></tr><tr><td class="label">First Name * : </td><td><input class="input"  type="text" value="" name="field_9171" id="field_9171"  /></td></tr><tr><td class="label">Last Name * : </td><td><input class="input"  type="text" value="" name="field_9172" id="field_9172"  /></td></tr><tr><td class="label">Email * : </td><td><input class="input"  type="text" value="" name="field_9173" id="field_9173"  /></td></tr><tr><td class="label">Contact Phone Number * : </td><td><input class="input"  type="text" value="" name="field_9174" id="field_9174"  /></td></tr><tr><td class="label">City * : </td><td><input class="input"  type="text" value="" name="field_9175" id="field_9175"  /></td></tr><tr><td class="label">State * : </td><td><input class="input"  type="text" value="" name="field_9176" id="field_9176"  /></td></tr><tr><td class="label">Are you currently experiencing symptoms or pain? * : </td><td><select class="input"  name="field_9177" id="field_9177" ><option value="Yes" >Yes</option><option value="No" >No</option></select></td></tr><tr><td class="label">If so, please explain  : </td><td><textarea class="input"  name="field_9178" id="field_9178" ></textarea></td></tr><tr><td rowspan="2" class="label">Please copy the 5 characters :</td><td><img src="" id="captcha_img_1666" /></td></tr><tr><td><input type="text" name="captcha" id="captcha_1666" size="6" /></tr><tr><td colspan="2" align="center"><br/><input type="submit" value="Submit" /></td></tr></table></form><script language="javascript">var now = new Date();document.getElementById(\'captcha_img_1666\').src = \'http://www.steeljaws.com/soap.php?todo=form_captcha_img&session_index=wetoform_1666&nocache=\'+now.getTime();</script>')