document.write('<style type="text/css">.form_table {background-color:#B2F9CA;}.label {border: solid 1px #ffffff;color:#000000;font-family:Arial;font-size:12px;border-color:#01FF91;}.input {border: solid 1px #ccc;background-color:#ffffff;font-family:Arial;color:#000000;font-size:12px;}</style><script language="javascript">function check_field_2566() {var a_field_ids = new Array(\'field_14313\',\'field_14314\',\'field_14315\',\'field_14316\',\'captcha_2566\');var a_field_labels = new Array(\'First Name\',\'Phone\',\'Email\',\'Are you currently experiencing pain or discomfot?\',\'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( \'field_14315\');var a_email_field_labels = new Array( \'Email\');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=2566" onSubmit="return(check_field_2566());" ><input type="hidden" name="formsubmit" value="1"><input type="hidden" name="form_url" value=""><table class="form_table"><tr><td colspan="2"><p align="center"><span class="text_green">Fill out the following form&nbsp;to receive a free copy of my Ebook that is packed with valuable information on:&nbsp;<br /><font size="3"><strong>7 Steps to a Pain Free Energy Filled Life.</strong></font></span><strong> <br /></strong></p><br/><br/></td></tr><tr><td class="label">First Name * : </td><td><input class="input"  type="text" value="" name="field_14313" id="field_14313"  /></td></tr><tr><td class="label">Phone * : </td><td><input class="input"  type="text" value="" name="field_14314" id="field_14314"  /></td></tr><tr><td class="label">Email * : </td><td><input class="input"  type="text" value="" name="field_14315" id="field_14315"  /></td></tr><tr><td class="label">Are you currently experiencing pain or discomfot? * : </td><td><select class="input"  name="field_14316" id="field_14316" ><option value="Yes" >Yes</option><option value="No" >No</option></select></td></tr><tr><td class="label">If yes, please explain  : </td><td><textarea class="input"  name="field_14317" id="field_14317" ></textarea></td></tr><tr><td rowspan="2" class="label">Please copy the 5 characters :</td><td><img src="" id="captcha_img_2566" /></td></tr><tr><td><input type="text" name="captcha" id="captcha_2566" 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_2566\').src = \'http://www.steeljaws.com/soap.php?todo=form_captcha_img&session_index=wetoform_2566&nocache=\'+now.getTime();</script>')