<head>
<script src="http://www.jotform.com/min/g=jotform&" type="text/javascript"></script>
<script type="text/javascript">

   JotForm.init();
</script>
<link type="text/css" rel="stylesheet" href="http://www.jotform.com/css/styles/form.css"/><link href="http://www.jotform.com/css/calendarview.css" rel="stylesheet" type="text/css" /><style type="text/css">
@font-face {
	font-family: 'JournalRegular';
	src: url('journal.eot');
	src: local('☺'), url('journal.woff') format('woff'), url('journal.ttf') format('truetype'), url('journal.svg#webfont1wv3wGdI') format('svg');
	font-weight: normal;
	font-style: normal;
}

    body { margin:0px; background:url(images/twiid.png); font-family: 'JournalRegular', Georgia }
    .form-label{
        width:150px !important; float:left;
    }
    li { list-style: none; }
    .form-label-left{
        width:150px !important; float:left;
    }
    .form-line{
        padding:10px; margin:0px;
    }
    ul { margin:10px; padding:0px; }
    .form-label-right{
        width:150px !important;
    }
    .form-all{
        width:450px !important;
        color:#ff9900;
        font-family:Verdana;
        font-size:12px;
        background: transparent url(images/twiid.png) ;
        
    }
    .form-textbox { font-size:12px; height:26px; padding-left:5px;}
        input,textarea,select,button { color:#ffae00; background:#3a1a00;  }
	button { width:75px; height:25px; }
    input,textarea,button { border-top:2px solid #b85100; border-right:2px solid #b85100; border-bottom:2px solid #6a2f00; border-left:2px solid #6a2f00; border-radius:10px; -webkit-border-radius:10px; -moz-border-radius:10px; -khtml-border-radius:10px; }
    .form-textbox, .form-input { border-radius:7px; -webkit-border-radius:7px; -moz-border-radius:7px; -khtml-border-radius:7px; }
</style>
<script type="text/javascript">

  var _gaq = _gaq || [];
  _gaq.push(['_setAccount', 'UA-18505670-1']);
  _gaq.push(['_trackPageview']);

  (function() {
    var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true;
    ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js';
    var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s);
  })();

</script>
</head><body>
<div>
<form class="jotform-form" action="http://www.jotform.com/submit.php" method="post" name="form_10755123229" id="10755123229" accept-charset="utf-8">
    <input type="hidden" name="formID" value="10755123229" />
    <div class="form-all" style="margin:0px auto 0px auto;">
        <ul class="form-section">
            <li class="form-line" id="id_0">
                <label class="form-label-left" id="label_0" for="input_0">
                    Name<span class="form-required">*</span>
                </label>
                <div id="id_0" class="form-input">
                    <input type="text" class="form-textbox validate[required]" id="input_0" name="q0_name" size="30" maxlength="100" />
                </div>
            </li>
            <li class="form-line" id="id_1">
                <label class="form-label-left" id="label_1" for="input_1">
                    Email<span class="form-required">*</span>
                </label>
                <div id="id_1" class="form-input">
                    <input type="text" class="form-textbox validate[required, Email]" id="input_1" name="q1_email1" size="30" maxlength="100" />
                </div>
            </li>
            <li class="form-line" id="id_9">
                <label class="form-label-left" id="label_9" for="input_9"> What's Up? </label>
                <div id="id_9" class="form-input">
                    <select class="form-dropdown" style="width:150px" id="input_9" name="q9_whatsUp">
                        <option>  </option>
                        <option value="Question"> Question </option>
                        <option value="Comment"> Comment </option>
                        <option value="Concern"> Concern </option>
                        <option value="Appointment Changes"> Appointment Changes </option>
                        <option value="Appointment Cancellations"> Appointment Cancellations </option>
                    </select>
                </div>
            </li>
            <li class="form-line" id="id_6">
                <label class="form-label-left" id="label_6" for="input_6">
                    Your Message:<span class="form-required">*</span>
                </label>
                <div id="id_6" class="form-input">
                    <textarea id="input_6" class="form-textarea validate[required]" name="q6_yourMessage" cols="30" rows="8"></textarea>
                </div>
            </li>
            <li class="form-line" id="id_7">
                <div id="id_7" class="form-input-wide">
                    <div style="text-align:center">
                        <button id="input_7" type="submit" class="form-submit-button">
                            Submit
                        </button>
                    </div>
                </div>
            </li>
            <li style="display:none">
                Should be Empty:
                <input type="text" name="website" value="" />
            </li>
        </ul>
    </div>
    <input type="hidden" id="simple_spc" name="simple_spc" value="10755123229" />
    <script type="text/javascript">
        document.getElementById("si" + "mple" + "_spc").value = "10755123229-10755123229";
    </script>
</form>
</div>
</body>�