<% @Language="VBScript" %>
<% Option Explicit %>
<%
Dim fname, lname, social_sec, status, birthdate, phone_home, phone_work
Dim current_address, current_city, current_state, current_zip, country
Dim perm_address, perm_city, perm_state, perm_zip
Dim referred_doc, referred_pat
Dim phoenix, mesa, scottsdale, new_times, arizona, internet, billboard, office, other, other2
Dim allergy, illness, medication
Dim nose, chin, cheeks, eyelids, face, rejuv, ears, collagen, breast
Dim tummy, glycolic, lipo, facial, body, laser
Dim condition, chosen, when, payment, docs, article, friends, friends2, object
Dim happy, insurance, insurance2
Dim error_string, post, success

Function Tab(n)
	Tab = String(n,vbTab)
End Function

fname = Request.Form("fname")
lname = Request.Form("lname")
social_sec = Request.Form("social_sec")
status = Request.Form("status")
birthdate = Request.Form("birthdate")
phone_home = Request.Form("phone_home")
phone_work = Request.Form("phone_work")
current_address = Request.Form("current_address")
current_city = Request.Form("current_city")
current_state = Request.Form("current_state")
current_zip = Request.Form("current_zip")
country = Request.Form("country")
perm_address = Request.Form("perm_address")
perm_city = Request.Form("perm_city")
perm_state = Request.Form("perm_state")
perm_zip = Request.Form("perm_zip")
referred_doc = Request.Form("referred_doc")
referred_pat = Request.Form("referred_pat")
phoenix = Request.Form("phoenix")
mesa = Request.Form("mesa")
scottsdale = Request.Form("scottsdale")
new_times = Request.Form("new_times")
arizona = Request.Form("arizona")
internet = Request.Form("internet")
billboard = Request.Form("billboard")
office = Request.Form("office")
other = Request.Form("other")
other2 = Request.Form("other2")
allergy = Request.Form("allergy")
illness = Request.Form("illness")
medication = Request.Form("medication")
nose = Request.Form("nose")
chin = Request.Form("chin")
cheeks = Request.Form("cheeks")
eyelids = Request.Form("eyelids")
face = Request.Form("face")
rejuv = Request.Form("rejuv")
ears = Request.Form("ears")
collagen = Request.Form("collagen")
breast = Request.Form("breast")
tummy = Request.Form("tummy")
glycolic = Request.Form("glycolic")
lipo = Request.Form("lipo")
facial = Request.Form("facial")
body = Request.Form("body")
laser = Request.Form("laser")
condition = Request.Form("condition")
chosen = Request.Form("chosen")
when = Request.Form("when")
payment = Request.Form("payment")
docs = Request.Form("docs")
article = Request.Form("article")
friends = Request.Form("friends")
friends2 = Request.Form("friends2")
object = Request.Form("object")
happy = Request.Form("happy")
insurance = Request.Form("insurance")
insurance2 = Request.Form("insurance2")
post = Request.Form("post")

error_string=""

If fname = "" Then
      error_string = error_string & "Please enter a first name. "
End If
If lname = "" Then
      error_string = error_string & "Please enter a last name. "
End If
If social_sec = "" Then
      error_string = error_string & "Please enter your social security number. "
End If
If birthdate = "" Then
	error_string = error_string & "Please enter a birthdate. "
ElseIf Not IsDate(birthdate) Then
    error_string = error_string & "Invalid birthdate entered. "
End If

If error_string = "" And post = "T" Then

Dim objMail, Message
Dim pickS, pickM, pickW, pickD
Dim birthday, ssn
Dim cash, cashier, card
Dim docsy, docsn, articley, articlen, friendsy, friendsn
Dim objecty, objectn, insurancey, insurancen
Dim city_state_zip, city_state_zip2, line

success = "T"

If status = "S" Then
	pickS = "X"
Else
	pickS = "--"
End If
If status = "M" Then
	pickM = "X"
Else
	pickM = "--"
End If
If status = "W" Then
	pickW = "X"
Else
	pickW = "--"
End If
If	status = "D" Then
	pickD = "X"
Else
	pickD = "--"
End If
birthday = FormatDateTime(birthdate,2)
If InStr(social_sec,"-") = 0 Then
	ssn = Left(social_sec,3) & "-" & Mid(social_sec,4,2) & "-" & Mid(social_sec,6)
Else
	ssn = social_sec
End If
If phoenix ="Y" Then
	phoenix = "X"
Else
	phoenix = "-"
End If
If mesa ="Y" Then
	mesa = "X"
Else
	mesa = "-"
End If
If scottsdale ="Y" Then
	scottsdale = "X"
Else
	scottsdale = "-"
End If
If new_times ="Y" Then
	new_times = "X"
Else
	new_times = "-"
End If
If arizona ="Y" Then
	arizona = "X"
Else
	arizona = "-"
End If
If internet ="Y" Then
	internet = "X"
Else
	internet = "-"
End If
If billboard ="Y" Then
	billboard = "X"
Else
	billboard = "-"
End If
If office ="Y" Then
	office = "X"
Else
	office = "-"
End If
If other ="Y" Then
	other = "X"
Else
	other = "-"
End If
If nose = "Y" Then
	nose = "X"
Else
	nose = "-"
End If
If chin = "Y" Then
	chin = "X"
Else
	chin = "-"
End If
If cheeks = "Y" Then
	cheeks = "X"
Else
	cheeks = "-"
End If
If eyelids = "Y" Then
	eyelids = "X"
Else
	eyelids = "-"
End If
If face = "Y" Then
	face = "X"
Else
	face = "-"
End If
If rejuv = "Y" Then
	rejuv = "X"
Else
	rejuv = "-"
End If
If ears = "Y" Then
	ears = "X"
Else
	ears = "-"
End If
If collagen = "Y" Then
	collagen = "X"
Else
	collagen = "-"
End If
If breast = "Y" Then
	breast = "X"
Else
	breast = "-"
End If
If tummy = "Y" Then
	tummy = "X"
Else
	tummy = "-"
End If
If laser = "Y" Then
	laser = "X"
Else
	laser = "-"
End If
If glycolic = "Y" Then
	glycolic = "X"
Else
	glycolic = "-"
End If
If lipo = "Y" Then
	lipo = "X"
Else
	lipo = "-"
End If
If facial = "Y" Then
	facial = "X"
Else
	facial = "-"
End If
If body = "Y" Then
	body = "X"
Else
	body = "-"
End If
If payment = "C" Then
	cash = "X"
Else
	cash = "-"
End If
If payment = "H" Then
	cashier = "X"
Else
	cashier = "-"
End If
If payment = "A" Then
	card = "X"
Else
	card = "-"
End If
If docs = "Y" Then
	docsy = "X"
Else
	docsy = "-"
End If
If docs = "N" Then
	docsn = "X"
Else
	docsn = "-"
End If
If article = "Y" Then
	articley = "X"
Else
	articley = "-"
End If
If article = "N" Then
	articlen = "X"
Else
	articlen = "-"
End If
If friends = "Y" Then
	friendsy = "X"
Else
	friendsy = "-"
End If
If friends = "N" Then
	friendsn = "X"
Else
	friendsn = "-"
End If
If object = "Y" Then
	objecty = "X"
Else
	objecty = "-"
End If
If object = "N" Then
	objectn = "X"
Else
	objectn = "-"
End If
If insurance = "Y" Then
	insurancey = "X"
Else
	insurancey = "-"
End If
If insurance = "N" Then
	insurancen = "X"
Else
	insurancen = "-"
End If

city_state_zip = current_city & ", " & current_state & " " & current_zip
city_state_zip2 = perm_city & ", " & perm_state & " " & perm_zip
line = "---------------------------------------------------------------"

Message = Tab(4) & "The Blumberg Center" & vbCrLf
Message = Message & Tab(4) & "   Patient Form" & vbCrLf
Message = Message & vbCrLf
Message = Message & line & vbCrLf
Message = Message & Tab(4) & "PATIENT INFO" & vbCrLf
Message = Message & line & vbCrLf
Message = Message & fname & " " & lname & vbCrLf
Message = Message & pickS & " Single " & pickM & " Married " & pickW & " Wid " & pickD & " Div" & vbCrLf
Message = Message & vbCrLf
Message = Message & "Soc. Sec. # " & ssn & vbCrLf
Message = Message & vbCrLf
Message = Message & "Date of Birth: " & birthday & vbCrLf
Message = Message & vbCrLf
Message = Message & "Home Phone # " & phone_home & " Work Phone # " & phone_work & vbCrLf
Message = Message & vbCrLf
Message = Message & "Present Address:" & vbCrLf
Message = Message & current_address & vbCrLf
Message = Message & city_state_zip & vbCrLf
Message = Message & country & vbCrLf
Message = Message & vbCrLf
Message = Message & "Permanent Address:" & vbCrLf
Message = Message & perm_address & vbCrLf
Message = Message & city_state_zip2 & vbCrLf
Message = Message & vbCrLf
Message = Message & line & vbCrLf
Message = Message & Tab(4) & "REFERRAL INFO" & vbCrLf
Message = Message & line & vbCrLf
Message = Message & "Referred by Dr.: " & referred_doc & "   Patient Referral: " & referred_pat & vbCrLf
Message = Message & vbCrLf
Message = Message & line & vbCrLf
Message = Message & Tab(4) & "OTHER INFO" & vbCrLf
Message = Message & line & vbCrLf
Message = Message & "How did you hear about us?" & vbCrLf
Message = Message & vbCrLf
Message = Message & "Yellow Pages:     " & phoenix & " Phoenix   " & mesa & " Mesa   " & scottsdale & " Scottsdale" & vbCrLf
Message = Message & new_times & " New Times " & arizona & " Today's Arizons Woman" & vbCrLf
Message = Message & internet & " Internet  " & billboard & " Billboard   " & office & " Office" & vbCrLf
Message = Message & other & " Other: " & other2 & vbCrLf
Message = Message & vbCrLf
Message = Message & line & vbCrLf
Message = Message & Tab(4) & "MEDICATION INFO" & vbCrLf
Message = Message & line & vbCrLf
Message = Message & "Any known allergies to medication? " & allergy & vbCrLf
Message = Message & vbCrLf
Message = Message & "Any known illnesses/diseases? " & illness & vbCrLf
Message = Message & vbCrLf
Message = Message & "List all the medications currently being used, including across" & vbCrLf
Message = Message & "the counter products:" & vbCrLf
Message = Message & medication & vbCrLf
Message = Message & vbCrLf
Message = Message & line & vbCrLf
Message = Message & Tab(4) & "SURGERY INFO" & vbCrLf
Message = Message & line & vbCrLf
Message = Message & "Please check the type of surgery you are considering:" & vbCrLf
Message = Message & vbCrLf
Message = Message & nose & " Nose   " & chin & " Chin   " & cheeks & " Cheeks   " & eyelids & " Eyelids   " & face & " Face   " & vbCrLf
Message = Message & rejuv & " Facial Rejuvenation   " & ears & " Ears   " & collagen & " Collagen/Gortex/Lip Advancement   " & vbCrLf
Message = Message & breast & " Breast Augmentation   " & tummy & " Tummy Tuck   " & laser & " Laser   " & vbCrLf
Message = Message & glycolic & " Glycolic Washes   " & lipo & " Liposuction   " & facial & " Facial   " & body & " Body   " & vbCrLf
Message = Message & vbCrLf
Message = Message & "What don't you like about the above conditions?" & vbCrLf
Message = Message & condition & vbCrLf
Message = Message & vbCrLf
Message = Message & "Why have you chosen the Blumberg Center?" & vbCrLf
Message = Message & chosen & vbCrLf
Message = Message & vbCrLf
Message = Message & "When do you expect to have the surgical procedure(s)?" & vbCrLf
Message = Message & when & vbCrLf
Message = Message & vbCrLf
Message = Message & line & vbCrLf
Message = Message & Tab(4) & "PAYMENT INFO" & vbCrLf
Message = Message & line & vbCrLf
Message = Message & "Method of Payment (Deposit required to reserve specific surgical date)." & vbCrLf
Message = Message & cash & " Cash  " & cashier & " Cashier's Check  " & card & " Credit Card" & vbCrLf
Message = Message & vbCrLf
Message = Message & line & vbCrLf
Message = Message & Tab(4) & "ADDITIONAL INFO" & vbCrLf
Message = Message & line & vbCrLf
Message = Message & "Check the following answers:" & vbCrLf
Message = Message & docsy & " Yes  " & docsn & " No   Have you consulted any other doctor about this?" & vbCrLf
Message = Message & articley & " Yes  " & articlen & " No   Have you read any article(s) about cosmetic surgery?" & vbCrLf
Message = Message & friendsy & " Yes  " & friendsn & " No   Have any friends or family had cosmetic surgery? If yes, what was done?" & vbCrLf
Message = Message & friends2 & vbCrLf
Message = Message & objecty & " Yes  " & objectn & " No   Do you understand that the object of cosmetic surgery is improvement, NOT perfection?" & vbCrLf
Message = Message & vbCrLf
Message = Message & "If you have cosmetic surgery, who do you think will be the happiest with the results?" & vbCrLf
Message = Message & happy & vbCrLf
Message = Message & vbCrLf
Message = Message & insurancey & " Yes  " & insurancen & " No   Do you have health insurance?  If yes, what kind?" & vbCrLf
Message = Message & insurance2 & vbCrLf
Message = Message & line

Set objMail = CreateObject("CDONTS.NewMail")
objMail.From="forms@blumbergcenter.com"
objMail.To="pblumb9952@aol.com"
' objMail.To="josh@webplexus.com"
objMail.Subject="Blumberg Center Patient Form"
objMail.BodyFormat=1
objMail.MailFormat=1
objMail.Body=Message
objMail.Send

Set objMail = Nothing
End If


' Response.Write(Request.Form)
' Response.End
%>

<html>
<head>
<title>New Patients</title>
<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1">
<STYLE>
      body  { font-family: Arial, Helvetica, sans-serif; font-size:x-small }
      table { font-family: Arial, Helvetica, sans-serif; font-size:x-small }
      P     { font-family: Arial, Helvetica, sans-serif; font-size:x-small }
</STYLE>
<link rel='STYLESHEET' type='text/css' href='blumbergcenter.css'>
</head>
<script language="JavaScript"><!--

<% If Not error_string = "" And post = "T" Then
	Response.Write("alert('" & error_string & "');")
   End If %>
<% If success = "T" Then %>
	alert("Your Email has been sent");
<% End If %>

//--></script>


<body bgcolor="#FFFFFF">
<span class="SiteMapL1Link">
<table border="0" cellpadding="0" cellspacing="0" width="718px">
  <!--DWLayoutTable-->
  <tr> 
    <td height="91" colspan="3" class="SiteMapL1Link"><span class="SiteMapL1Link"> 
      <table border="0" cellpadding="0" cellspacing="0" class="navigation-top">
        <tr>
									<td align="center" class="SiteMapL1Link" colspan="3" height="2" width="718px"></td>
								</tr>
        <tr>
									<td align="center" class="SiteMapL1Link" colspan="3" height="5" width="718px"><span id="cell_2"><img border="0" height="84" src="images/title.jpg" width="619"></span></td>
								</tr>
        <tr>
									<td align="center" class="SiteMapL1Link" colspan="3" rowspan="2"></td>
								</tr>
        <tr> 
          <td align="center" class="SiteMapL1Link"></td>
          <td align="center" class="SiteMapL1Link"></td>
        </tr>
        <tr> 
          <td class="SiteMapL1Link" valign="bottom"></td>
									<td align="center" class="SiteMapL1Link"></td>
								</tr>
        <tr>
									<td class="SiteMapL1Link" colspan="3" height="5" width="718px"></td>
								</tr>
      </table>
      </span></td>
  </tr>
  <tr> 
    <td width="23" height="646">&nbsp;</td>
    <td width="679" valign="top" class="navigation-content">
						<form action="http://www.az-web.com/cgi-bin/formmail.pl" method="get" name="New Patients form">
							<input type="hidden" name="subject" value="new patient form" border="0"><input type="hidden" name="recipient" value="info@blumbergcenter.com" border="0"><input type="hidden" name="redirect" value="http://209.208.58.218/form.html" border="0">
							<table border="0" cellpadding="0" cellspacing="5px">
								<!--DWLayoutTable-->
								<tr>
									<td width="669"></td>
									<td></td>
									<td></td>
									<td></td>
								</tr>
								<TR>
									<td></td>
									<td></td>
									<td></td>
									<td></td>
									<form method="post" action="form.html">
										<img class="StoryImageHeadline" src="images/doc2.jpg" width="126" height="210"><span class="StoryHeadline"> </span><br class="hack" clear="left">
										<br class="hack" clear="left">
										<span class="StoryBody">Please print and fill out the patient form 
            below and bring it to your first appointment. <br class='cleanup'>
											<br class='cleanup'>
											
            By filling out this form before your appointment, you will save time 
            at the office and enjoy greater convenience.<br class='cleanup'>
										</span><br>
										<br>
										<input type="hidden" name="post" value="T">
										<table border=0 cellspacing="0" cellpadding="4">
											<tr>
												<td width="10%"><b>Patient First Name:<b></td>
												<td width="10%"><input type="text" name="fname" size="20" maxlength="30"></td>
												<td width="10%"><b>Patient Last Name:</b></td>
												<td width="10%"><input type="text" name="lname" size="20" maxlength="30"></td>
											</tr>
											<tr>
												<td width="10%"><b>Social Security #:</b></td>
												<td width="10%"><input type="text" name="social_sec" size="15" maxlength="12"></td>
												<td width="10%"><b>Marital Status:</b></td>
												<td width="10%">
													<table>
														<tr>
															<td width="50%"><INPUT type="radio" name="status" value="M" <% If status = "M" Then Response.Write("CHECKED") %>/>
                        Married</td>
															<td width="50%"><INPUT type="radio" name="status" value="S" <% If status = "S" Then Response.Write("CHECKED") %>/>
                        Single</td>
														</tr>
													</table>
												</td>
											</tr>
											<tr>
												<td><b>Birth Date:</b></td>
												<td><input type="text" name="birthdate" size="20" maxlength="10"></td>
												<TD>&nbsp;</TD>
												<td width="10%">
													<table>
														<tr>
															<td width="50%"><INPUT type="radio" name="status" value="W" <% If status = "W" Then Response.Write("CHECKED") %>/>
                        Widowed</td>
															<td width="50%"><INPUT type="radio" name="status" value="D" <% If status = "D" Then Response.Write("CHECKED") %>/>
                        Divorced</td>
														</tr>
													</table>
												</td>
											</tr>
											<tr>
												<td width="10%"><b>Home Phone #:</b></td>
												<td width="10%"><input type="text" name="phone_home" size="15" maxlength="20"></td>
												<td width="10%"><b>Work Phone #:</b></td>
												<td width="10%"><input type="text" name="phone_work" size="15" maxlength="25"></td>
											</tr>
											<tr>
												<td width="10%"><b>Present Address:</b></td>
												<td colspan="3"><input type="text" name="current_address" size="61" maxlength="60"></td>
											</tr>
											<tr>
												<td width="10%"><b>City:</b></td>
												<td width="10%"><input type="text" name="current_city" size="20" maxlength="25"></td>
												<td width="10%"><b>State:</b>&nbsp; <input NAME="current_state" TYPE="text" SIZE="7" maxlength="10" ></td>
												<td width="10%"><b>Zip:</b>&nbsp; <input type="text" name="current_zip" size="10" maxlength="10"></td>
											</tr>
											<tr>
												<td width="10%"><b>Country:</b></td>
												<td width="10%"><input type="text" name="country" size="20" maxlength="20"></td>
												<TD>&nbsp;</TD>
												<TD>&nbsp;</TD>
											</tr>
											<tr>
												<td width="10%"><b>Permanent Address:</b><br>
													<font size="-2">(if 
                  different than above)</font></td>
												<td colspan="3"><input type="text" name="perm_address" size="61" maxlength=60"></td>
											</tr>
											<tr>
												<td width="10%"><b>City:</b></td>
												<td width="10%"><input type="text" name="perm_city" size="20" maxlength="25"></td>
												<td width="10%"><b>State:</b>&nbsp; <input NAME="perm_state" TYPE="text" SIZE="7" maxlength="10" ></td>
												<td width="10%"><b>Zip:</b>&nbsp; <input type="text" name="perm_zip" size="10" maxlength="10"></td>
											</tr>
											<tr>
												<td width="10%"><b>Referred by Dr.</b></td>
												<td width="10%"><input type="text" name="referred_doc"></td>
												<td width="10%"><b>Patient Referral:</b></td>
												<td width="10%"><input type="text" name="referred_pat"></td>
											</tr>
											<tr>
												<td colspan="4"><b>How did you hear about us?</b></td>
											</tr>
											<tr>
												<td colspan="4">
													<table border=0 cellpadding="4" cellspacing="0">
														<tr>
															<td><b>Yellow Pages: </b></td>
															<td><INPUT type="checkbox" name="phoenix" value="Y" <% If phoenix = "Y" Then Response.Write("CHECKED") %>/>
                        Phoenix </td>
															<td><INPUT type="checkbox" name="mesa" value="Y" <% If mesa = "Y" Then Response.Write("CHECKED") %>/>
                        Mesa</td>
															<td colspan="2"><INPUT type="checkbox" name="scottsdale" value="Y" <% If scottsdale = "Y" Then Response.Write("CHECKED") %>/>
                        Scottsdale</td>
														</tr>
														<tr>
															<td>&nbsp;</td>
															<td><i><INPUT type="checkbox" name="new_times" value="Y" <% If new_times = "Y" Then Response.Write("CHECKED") %>/>
                        New Times</i></td>
															<td colspan="3"><i><INPUT type="checkbox" name="arizona" value="Y" <% If arizona = "Y" Then Response.Write("CHECKED") %>/>
                        Today's Arizona Woman</i></td>
														</tr>
														<tr>
															<td>&nbsp;</td>
															<td><INPUT type="checkbox" name="internet" value="Y" <% If internet = "Y" Then Response.Write("CHECKED") %>/>
                        Internet</td>
															<td><INPUT type="checkbox" name="billboard" value="Y" <% If billboard = "Y" Then Response.Write("CHECKED") %>/>
                        Billboard</td>
															<td><INPUT type="checkbox" name="office" value="Y" <% If office = "Y" Then Response.Write("CHECKED") %>/>
                        Office</td>
															<td><INPUT type="checkbox" name="other" value="Y" <% If other = "Y" Then Response.Write("CHECKED") %>/>
                        Other</td>
														</tr>
														<tr>
															<td colspan="4">&nbsp;</td>
															<td><input type="text" name="other2" size="30" maxlength="30"></td>
														</tr>
													</table>
												</td>
											</tr>
										</TABLE>
										<table border=0 cellspacing="0" cellpadding="4">
											<tr>
												<td width="45%"><b>Any known allergies to medication?<b></td>
												<td><input type="text" name="allergy" size="50" maxlength="50"></td>
												<td></td>
												<td></td>
											</tr>
											<tr>
												<td width="45%"><b>Any known illnesses/diseases?</b></td>
												<td><input type="text" name="illness" size="50" maxlength="50"></td>
												<td></td>
												<td></td>
											</tr>
											<tr>
												<td colspan="2"><b>List all the medications currently being used, 
                  including across the counter products:</b></td>
												<td></td>
												<td></td>
											</tr>
											<tr>
												<td colspan="2"><textarea rows="2" cols="63" name="medication"></textarea></td>
												<td></td>
												<td></td>
											</tr>
											<tr>
												<td colspan="2"><b>Please check the type of surgery you are considering:</b></td>
												<td></td>
												<td></td>
											</tr>
											<tr>
												<td colspan="2">
													<table >
														<tr>
															<td><INPUT type="checkbox" name="nose" value="Y" <% If nose = "Y" Then Response.Write("CHECKED") %>/>
                        Nose</td>
															<td><INPUT type="checkbox" name="chin" value="Y" <% If chin = "Y" Then Response.Write("CHECKED") %>/>
                        Chin</td>
															<td><INPUT type="checkbox" name="cheeks" value="Y" <% If cheeks = "Y" Then Response.Write("CHECKED") %>/>
                        Cheeks</td>
															<td><INPUT type="checkbox" name="eyelids" value="Y" <% If eyelids = "Y" Then Response.Write("CHECKED") %>/>
                        Eyelids</td>
															<td><INPUT type="checkbox" name="face" value="Y" <% If face = "Y" Then Response.Write("CHECKED") %>/>
                        Face</td>
															<td><INPUT type="checkbox" name="rejuv" value="Y" <% If rejuv = "Y" Then Response.Write("CHECKED") %>/>
                        Facial Rejuvenation</td>
															<td><INPUT type="checkbox" name="ears" value="Y" <% If ears = "Y" Then Response.Write("CHECKED") %>/>
                        Ears</td>
														</tr>
														<tr>
															<td colspan="4"><INPUT type="checkbox" name="collagen" value="Y" <% If collagen = "Y" Then Response.Write("CHECKED") %>/>
                        Collegen/Gortex/Lip Advancement</td>
															<td colspan="2"><INPUT type="checkbox" name="breast" value="Y" <% If breast = "Y" Then Response.Write("CHECKED") %>/>
                        Breast Augmentation</td>
															<td colspan="1"><INPUT type="checkbox" name="tummy" value="Y" <% If tummy = "Y" Then Response.Write("CHECKED") %>/>
                        Tummy Tuck</td>
														</tr>
														<tr>
															<td colspan="2"><INPUT type="checkbox" name="glycolic" value="Y" <% If glycolic = "Y" Then Response.Write("CHECKED") %>/>
                        Glycolic Washes</td>
															<td colspan="2"><INPUT type="checkbox" name="lipo" value="Y" <% If lipo = "Y" Then Response.Write("CHECKED") %>/>
                        Liposuction</td>
															<td><INPUT type="checkbox" name="facial" value="Y" <% If facial = "Y" Then Response.Write("CHECKED") %>/>
                        Facial</td>
															<td><INPUT type="checkbox" name="body" value="Y" <% If body = "Y" Then Response.Write("CHECKED") %>/>
                        Body</td>
															<td><INPUT type="checkbox" name="laser" value="Y" <% If laser = "Y" Then Response.Write("CHECKED") %>/>
                        Laser</td>
														</tr>
													</table>
												</td>
												<td></td>
												<td></td>
											</tr>
											<tr>
												<td colspan="2"><b>What don&acute;t you like about the above conditions?</b></td>
												<td></td>
												<td></td>
											</tr>
											<tr>
												<td colspan="2"><textarea rows="2" cols="63" name="condition"></textarea></td>
												<td></td>
												<td></td>
											</tr>
											<tr>
												<td colspan="2"><b>Why have you chosen the Blumberg Center?</b></td>
												<td></td>
												<td></td>
											</tr>
											<tr>
												<td colspan="2"><textarea rows="2" cols="63" name="chosen"></textarea></td>
												<td></td>
												<td></td>
											</tr>
											<tr>
												<td colspan="2"><b>When do you expect to have the surgical procedure(s)?</b></td>
												<td></td>
												<td></td>
											</tr>
											<tr>
												<td colspan="2"><textarea rows="2" cols="63" name="when"></textarea></td>
												<td></td>
												<td></td>
											</tr>
											<tr>
												<td colspan="2"><b>Method of Payment (Deposit required to reserve 
                  specific surgical date).</b></td>
												<td></td>
												<td></td>
											</tr>
										</TABLE>
										<table border=0  cellspacing="0" cellpadding="4">
											<tr>
												<td><INPUT type="radio" name="payment" value="C" <% If payment = "C" Then Response.Write("CHECKED") %>/>
                  Cash</td>
												<td><INPUT type="radio" name="payment" value="H" <% If payment = "H" Then Response.Write("CHECKED") %>/>
                  Cashier's Check</td>
												<td><INPUT type="radio" name="payment" value="A" <% If payment = "A" Then Response.Write("CHECKED") %>/>
                  Credit Card</td>
												<td></td>
											</tr>
										</TABLE>
										<table border=0  cellspacing="0" cellpadding="4">
											<tr>
												<td colspan="3"><b>Check the following answers:</b></td>
												<td></td>
											</tr>
											<tr>
												<td width="10%"><INPUT type="radio" name="docs" value="Y" <% If docs = "Y" Then Response.Write("CHECKED") %>/>
                  Yes</td>
												<td width="10%"><INPUT type="radio" name="docs" value="N" <% If docs = "N" Then Response.Write("CHECKED") %>/>
                  No</td>
												<td>Have you consulted any other doctors about this?</td>
												<td></td>
											</tr>
											<tr>
												<td width="10%"><INPUT type="radio" name="article" value="Y" <% If article = "Y" Then Response.Write("CHECKED") %>/>
                  Yes</td>
												<td width="10%"><INPUT type="radio" name="article" value="N" <% If article = "N" Then Response.Write("CHECKED") %>/>
                  No</td>
												<td>Have you read any article(s) about cosmetic surgery?</td>
												<td></td>
											</tr>
											<tr>
												<td width="10%"><INPUT type="radio" name="friends" value="Y" <% If friends = "Y" Then Response.Write("CHECKED") %>/>
                  Yes</td>
												<td width="10%"><INPUT type="radio" name="friends" value="N" <% If friends = "N" Then Response.Write("CHECKED") %>/>
                  No</td>
												<td>Have any friends or family had cosmetic surgery? If yes, what 
                  was done?</td>
												<td></td>
											</tr>
											<tr>
												<td></td>
												<td></td>
												<td colspan="2"><input type="text" name="friends2" size="50" maxlength="50"></td>
											</tr>
											<tr>
												<td width="10%"><INPUT type="radio" name="object" value="Y" <% If object = "Y" Then Response.Write("CHECKED") %>/>
                  Yes</td>
												<td width="10%"><INPUT type="radio" name="object" value="N" <% If object = "N" Then Response.Write("CHECKED") %>/>
                  No</td>
												<td>Do you understand that the object of cosmetic surgery is improvement, 
                  NOT perfection?</td>
												<td></td>
											</tr>
											<tr>
												<td colspan="3">If you have cosmetic surgery, who do you think 
                  will be the happiest with the results?</td>
												<td></td>
											</tr>
											<tr>
												<td colspan="3"><input type="text" name="happy" size="75" maxlength="75"></td>
												<td></td>
											</tr>
											<tr>
												<td width="10%"><INPUT type="radio" name="insurance" value="Y" <% If insurance = "Y" Then Response.Write("CHECKED") %>/>
                  Yes</td>
												<td width="10%"><INPUT type="radio" name="insurance" value="N" <% If insurance = "N" Then Response.Write("CHECKED") %>/>
                  No</td>
												<td>Do you have health insurance? If yes, what kind?</td>
												<td></td>
											</tr>
											<tr>
												<td>&nbsp;</td>
												<td>&nbsp;</td>
												<td><input type="text" name="insurance2" size="50" maxlength="35"></td>
												<td></td>
											</tr>
											<tr>
												<td colspan="3" align="center"><input type="submit" name="email_button" value="Email"> 
                  &nbsp;&nbsp; <input type="submit" name="reset_button" value="Reset"></td>
												<td></td>
											</tr>
										</table>
									</form>
								</TR>
							</table>
						</form>
					</td>
  <td width="16">&nbsp;</td>
  </tr>
</table>
</span>
</body>
</html>