document.write('<style type="text/css">.form_table {background-color:#ffffff;}.label {border: solid 1px #ffffff;color:#000000;font-family:Arial;font-size:12px;font-weight:bold;border-color:#FFFFFF;}.input {border: solid 1px #ccc;background-color:#ffffff;font-family:Arial;color:#000000;font-size:12px;}</style><script language="javascript">function check_field_3224() {var a_field_ids = new Array(\'field_18909\',\'field_18910\',\'field_18911\',\'field_18912\',\'field_18913\',\'field_18914\',\'field_18915\',\'captcha_3224\');var a_field_labels = new Array(\'Name\',\'Email\',\'Phone\',\'City\',\'State\',\'Please describe your condition and symptoms\',\'What, if any, treatments have you had for this problem?\',\'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=3224" onSubmit="return(check_field_3224());" ><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.<br/><br/></td></tr><tr><td class="label">Name * : </td><td><input class="input"  type="text" value="" name="field_18909" id="field_18909"  /></td></tr><tr><td class="label">Email * : </td><td><input class="input"  type="text" value="" name="field_18910" id="field_18910"  /></td></tr><tr><td class="label">Phone * : </td><td><input class="input"  type="text" value="" name="field_18911" id="field_18911"  /></td></tr><tr><td class="label">City * : </td><td><input class="input"  type="text" value="" name="field_18912" id="field_18912"  /></td></tr><tr><td class="label">State * : </td><td><input class="input"  type="text" value="" name="field_18913" id="field_18913"  /></td></tr><tr><td class="label">Please describe your condition and symptoms * : </td><td><textarea class="input"  name="field_18914" id="field_18914" ></textarea></td></tr><tr><td class="label">What, if any, treatments have you had for this problem? * : </td><td><textarea class="input"  name="field_18915" id="field_18915" ></textarea></td></tr><tr><td rowspan="2" class="label">Please copy the 5 characters :</td><td><img src="" id="captcha_img_3224" /></td></tr><tr><td><input type="text" name="captcha" id="captcha_3224" 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_3224\').src = \'http://www.steeljaws.com/soap.php?todo=form_captcha_img&session_index=wetoform_3224&nocache=\'+now.getTime();</script>')