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 #000000; background-color:#ffffff; font-family:Arial; color: #000000; font-size:12px;}</style><script language="javascript">function check_field_2616() {var a_field_ids = new Array(\'field_14613\',\'captcha_2616\');var a_field_labels = new Array(\'Email address\',\'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_14613\');var a_email_field_labels = new Array( \'Email address\');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=2616" onSubmit="return(check_field_2616());" ><input type="hidden" name="formsubmit" value="1"><input type="hidden" name="form_url" value=""><table class="form_table"><tr><td colspan="2"><p>Please enter your email address to receive our monthly newsletter including special offers and medical updates</p><br/><br/></td></tr><tr><td class="label">Email address * : </td><td><input class="input"  type="text" value="" name="field_14613" id="field_14613"  /></td></tr><tr><td rowspan="2" class="label">Please copy the 5 characters :</td><td><img src="" id="captcha_img_2616" /></td></tr><tr><td><input type="text" name="captcha" id="captcha_2616" 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_2616\').src = \'http://www.steeljaws.com/soap.php?todo=form_captcha_img&session_index=wetoform_2616&nocache=\'+now.getTime();</script>')