// JavaScript Document

var str="";
str="<form action=\"http://pumc.com/clientdatabase/email_backup(good).asp\" method=\"post\" onsubmit=\"return FrontPage_Form1_Validator(this)\">                                        <input type=\"hidden\" name=\"doc_email\" value=\"thankyouforcontactingus@allurefacialsurgery.com\" />              <input type=\"hidden\" name=\"submitpage\" value=\"http://pumc.com/clientdatabase/email_backup(good).asp\" />                          <fieldset>                                             <h3 class=\"ttl-contact\">Contact Us</h3>                                             <p>Required *</p>                                             <div class=\"inp-hold\">                                                  <!--webbot bot=\"Validation\" b-value-required=\"TRUE\" i-maximum-length=\"50\" -->                                                  <input type=\"text\" value=\"First Name *\" name=\"name\" onfocus=\" if (this.value == 'First Name *') { this.value = ''; }\" onblur=\"if (this.value == '') { this.value='First Name *';} \"/>                                             </div>                                             <div class=\"inp-hold\">                                                  <!--webbot bot=\"Validation\" b-value-required=\"TRUE\" i-maximum-length=\"50\" -->                                                  <input type=\"text\" value=\"Last Name *\" name=\"nameLast\" onfocus=\" if (this.value == 'Last Name *') { this.value = ''; }\" onblur=\"if (this.value == '') { this.value='Last Name *';} \"/>                                             </div>                                             <div class=\"inp-hold\">                                                  <!--webbot bot=\"Validation\" b-value-required=\"TRUE\" i-maximum-length=\"50\" -->                                                  <input type=\"text\" value=\"Email Address *\" name=\"EmailAddress\" onfocus=\" if (this.value == 'Email Address *') { this.value = ''; }\" onblur=\"if (this.value == '') { this.value='Email Address *';} \"/>                                             </div>                                             <div class=\"inp-hold\">                                                  <!--webbot bot=\"Validation\" b-value-required=\"TRUE\" i-maximum-length=\"50\" -->                                                  <input type=\"text\" value=\"Mobile Phone *\" name=\"Phone\" onfocus=\" if (this.value == 'Mobile Phone *') { this.value = ''; }\" onblur=\"if (this.value == '') { this.value='Mobile Phone *';} \"/>                                             </div>                                             <!--webbot bot=\"Validation\" b-value-required=\"TRUE\" b-disallow-first-item=\"TRUE\" -->                                             <select name=\"Procedure\">                                                  <option selected=\"selected\" value=\"\">Select A Procedure *</option>                                                  <option value=\"Monthly Specials\">Monthly Specials</option>                                                  <option value=\"Botox&reg; Cosmetic\">Botox&reg; Cosmetic</option>                                                  <option value=\"Brow Lifts\">Brow Lifts</option>                                                  <option value=\"Chemical Peels\">Chemical Peels</option>                                                  <option value=\"Dermal Fillers\">Dermal Fillers</option>                                                  <option value=\"Eyelid Lifts\">Eyelid Lifts</option>                                                  <option value=\"Lunch Time Eyelid Lifts\">Lunch Time Eyelid Lifts</option>                                                  <option value=\"Hair Removal\">Hair Removal</option>                                                  <option value=\"Laser Skin Resurfacing\">Laser Skin Resurfacing</option>                                                  <option value=\"Microdermabrasion\">Microdermabrasion</option>                                                  <option value=\"Skin Care Programs\">Skin Care Programs</option>                                                  <option value=\"Other Procedures (please specify)\">Other Procedures (please specify)</option>                                                  <option value=\"Add me to your e-newsletter\">Add me to your e-newsletter</option>                                                  <option value=\"remove me from your e-newsletter list\">remove me from your e-newsletter list</option>                                             </select>                                             <div class=\"area-hold\">                                                  <textarea cols=\"20\" rows=\"3\" name=\"Comment\" onfocus=\" if (this.value == 'Questions/Comment') { this.value = ''; }\" onblur=\"if (this.value == '') { this.value='Questions/Comment';} \">Questions/Comment</textarea>                                             </div>                                             <input type=\"button\" class=\"btn\" value=\"reset\" />                                             <input type=\"submit\" class=\"btn\" value=\"submit\" />                                        </fieldset>                                        <input type=\"hidden\" name=\"return\" value=\"allurefacialsurgery.com\" />                                        <input type=\"hidden\" name=\"subject\" value=\"AllureFacialSurgery.com Website E-mail\" />                                   </form>";
document.write(str);