document.write('<style type="text/css">.form_table {background-color:#E1E1E1;}.label {border: solid 1px #ffffff;color:#000000;font-family:Arial;font-size:12px;border-color:#5911FF;}.input {border: solid 1px #ccc;color:#000000;font-family:Arial;font-size:12px;border-color:#070707;}</style><script language="javascript">function check_field_3283() {var a_field_ids = new Array(\'field_19250\',\'field_19251\',\'field_19252\',\'field_19253\',\'field_19254\',\'captcha_3283\');var a_field_labels = new Array(\'First Name\',\'Last Name\',\'Email\',\'Phone (with area code)\',\'Please identify if you have any current symptoms?\',\'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=3283" onSubmit="return(check_field_3283());" ><input type="hidden" name="formsubmit" value="1"><input type="hidden" name="form_url" value=""><table class="form_table"><tr><td colspan="2"><p>Please use the following form for obtaining a complimentary <br />health and/or pain relief consultation.</p><br/><br/></td></tr><tr><td class="label">First Name * : </td><td><input class="input"  type="text" value="" name="field_19250" id="field_19250"  /></td></tr><tr><td class="label">Last Name * : </td><td><input class="input"  type="text" value="" name="field_19251" id="field_19251"  /></td></tr><tr><td class="label">Email * : </td><td><input class="input"  type="text" value="" name="field_19252" id="field_19252"  /></td></tr><tr><td class="label">Phone (with area code) * : </td><td><input class="input"  type="text" value="" name="field_19253" id="field_19253"  /></td></tr><tr><td class="label">Please identify if you have any current symptoms? * : </td><td><select class="input"  name="field_19254" id="field_19254" ><option value="Select either YES" >Select either YES</option><option value=" or NO" > or NO</option><option value="YES" >YES</option><option value="NO" >NO</option></select></td></tr><tr><td class="label">If you selected YES, please mentions any symptoms.  : </td><td><textarea class="input"  name="field_19255" id="field_19255" ></textarea></td></tr><tr><td rowspan="2" class="label">Please copy the 5 characters :</td><td><img src="" id="captcha_img_3283" /></td></tr><tr><td><input type="text" name="captcha" id="captcha_3283" 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_3283\').src = \'http://www.steeljaws.com/soap.php?todo=form_captcha_img&session_index=wetoform_3283&nocache=\'+now.getTime();</script>')