document.write('<style type="text/css">.form_table {background-color:#F9F9CF;}.label {border: solid 1px #ffffff;font-size:12px;font-family:Arial;color:#000000;}.input {border: solid 1px #ccc;background-color:#ffffff;font-family:Arial;color:#000000;font-size:12px;}</style><script language="javascript">function check_field_414() {var a_field_ids = new Array(\'field_2522\',\'field_6460\',\'field_6461\',\'field_2523\',\'field_6462\',\'captcha_414\');var a_field_labels = new Array(\'First Name\',\'Last Name\',\'Contact Phone\',\'Email\',\'Are you experiencing any pain that you would like your massage to focus on?\',\'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=414" onSubmit="return(check_field_414());" ><input type="hidden" name="formsubmit" value="1"><input type="hidden" name="form_url" value=""><table class="form_table"><tr><td colspan="2"><p><font face="Verdana"></font></p><br/><br/></td></tr><tr><td class="label">First Name * : </td><td><input class="input"  type="text" value="" name="field_2522" id="field_2522"  /></td></tr><tr><td class="label">Last Name * : </td><td><input class="input"  type="text" value="" name="field_6460" id="field_6460"  /></td></tr><tr><td class="label">Contact Phone * : </td><td><input class="input"  type="text" value="" name="field_6461" id="field_6461"  /></td></tr><tr><td class="label">Email * : </td><td><input class="input"  type="text" value="" name="field_2523" id="field_2523"  /></td></tr><tr><td class="label">Are you experiencing any pain that you would like your massage to focus on? * : </td><td><select class="input"  name="field_6462" id="field_6462" ><option value="Yes" >Yes</option><option value="No" >No</option></select></td></tr><tr><td class="label">If yes, please provide comment  : </td><td><textarea class="input"  name="field_6463" id="field_6463" ></textarea></td></tr><tr><td rowspan="2" class="label">Please copy the 5 characters :</td><td><img src="" id="captcha_img_414" /></td></tr><tr><td><input type="text" name="captcha" id="captcha_414" 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_414\').src = \'http://www.steeljaws.com/soap.php?todo=form_captcha_img&session_index=wetoform_414&nocache=\'+now.getTime();</script>')