- Code: Select all
<p>Your Name: <input type="text" name="name" size="42"></p>
<p>Address: <input type="text" name="street" size="42"></p>
<p>City: <input type="text" name="city" size="20"> State <input type="text" name="state" size="3" value="AR"> Zip Code <input type="text" name="zip" size="10"></p>
<p>Day Phone: <input type="text" name="day_phone" size="20"> </p>
<p>Evening Phone: <input type="text" name="night_phone" size="20"></p>
<p>E-mail: <input type="text" name="email" size="40"></p>
<hr>
<p><strong>Would you like to schedule an appointment?</strong> <input type="radio" name="appt" value="YES_appt" id="ff_elem183"> <label id="ff_lbl183" for="ff_elem183">Yes </label>
<input type="radio" name="appt" value="NO_appt" id="ff_elem184"> <label id="ff_lbl184" for="ff_elem184">No </label></p>
<p>Please provide us with information about <br>
when you would like an appointment. <br>
We will call, write, or e-mail you <br>
with an appointment confirmation. </p>
<blockquote>
<p><strong>Month </strong>
<select NAME="month" id="ff_elem203" size="1">
<option SELECTED VALUE="none">Select Month</option>
<option VALUE="Jan">Jan</option>
<option VALUE="Feb">Feb</option>
<option VALUE="Mar">Mar</option>
<option VALUE="Apr">Apr</option>
<option VALUE="May">May</option>
<option VALUE="Jun">Jun</option>
<option VALUE="Jul">Jul</option>
<option VALUE="Aug">Aug</option>
<option VALUE="Sep">Sep</option>
<option VALUE="Oct">Oct</option>
<option VALUE="Nov">Nov</option>
<option VALUE="Dec">Dec</option>
</select></p>
<p><strong>Day</strong>
<select NAME="day" id="ff_elem204" size="1">
<option VALUE="none">Select Day</option>
<option VALUE="Monday">Monday</option>
<option VALUE="Tuesday">Tuesday</option>
<option VALUE="Wednesday">Wednesday</option>
<option VALUE="Thursday">Thursday</option>
<option VALUE="Friday">Friday</option>
</select></p>
<p><strong>Time</strong>
<input TYPE="radio" NAME="time" VALUE="morning" id="ff_elem185">
<label id="ff_lbl185" for="ff_elem185">Morning </label>
<input TYPE="radio" NAME="time" VALUE="afternoon" id="ff_elem186">
<label id="ff_lbl186" for="ff_elem186">Afternoon </label></p>
</blockquote>
<hr align="left">
<p><strong>I would like additional information about:</strong> </p>
<div align="left">
<table border="0" width="469" id="table4" align="left">
<tr>
<td width="155">
<p><input TYPE="checkbox" NAME="ff_nm_LASIK[]" VALUE="info" id="ff_elem193">
<label id="ff_lbl193" for="ff_elem193">LASIK </label></p>
<p><input TYPE="checkbox" NAME="ff_nm_Contacts[]" VALUE="info" id="ff_elem194">
<label id="ff_lbl194" for="ff_elem194">Contacts </label>
</td>
<td width="156">
<p><input TYPE="checkbox" NAME="ff_nm_Glasses[]" VALUE="info" id="ff_elem195">
<label id="ff_lbl195" for="ff_elem195">Glasses </label></p>
<p><input TYPE="checkbox" NAME="ff_nm_Cataracts[]" VALUE="info" id="ff_elem196">
<label id="ff_lbl196" for="ff_elem196">Cataracts </label>
</td>
<td width="156">
<p><input TYPE="checkbox" NAME="ff_nm_Glaucoma[]" VALUE="info" id="ff_elem197">
<label id="ff_lbl197" for="ff_elem197">Glaucoma </label></p>
<p><input TYPE="checkbox" NAME="ff_nm_Eyelid_Surgery[]" VALUE="info" id="ff_elem198">
<label id="ff_lbl198" for="ff_elem198">Eyelid Surgery </label>
</td>
</tr>
</table>
</div>
<p><input TYPE="checkbox" NAME="ff_nm_Other[]1" VALUE="info" id="ff_elem199">
<label id="ff_lbl199" for="ff_elem199">Other Information or Questions: </label></p>
<p><textarea COLS="30" NAME="other_info" id="ff_elem192" style="height: 63; width: 612" rows="3"></textarea></p>
<hr>
<p>The best way to contact me:
<input type="checkbox" name="contact" value="mail"> Mail
<input type="checkbox" name="contact" value="phone"> Telephone
<input type="checkbox" name="contact" value="email"> Email </p>
<hr>
<p>Use the space below for additional questions & comments:</p>
<p><textarea COLS="30" NAME="other_info0" id="ff_elem205" style="height: 63; width: 612" rows="3"></textarea></p>
<p><input type="submit" value="Send to Boozman-Hof" name="Submit" style="font-style: italic; font-weight: bold">
<input type="reset" value="Reset (cancel form)" name="reset" style="font-size: 8pt; font-style: oblique"></p>
<hr>
Post edited by: laurel, at: 2007/08/31 08:56
Edited for clarity, removed Mso classes and <form> tags.<br><br>Post edited by: GreyHead, at: 2007/08/31 10:57
