/*jslint nomen:false, debug:true, evil:true, vars:false, browser:true, forin:true, undef:false, white:false */
/**
* Includes a Form with javascript
* @param {Object} formId
* @param {Object} initialHeight
* @param {Object} iframeCode
*/
function FrameBuilder (formId, appendTo, initialHeight, iframeCode){
this.formId = formId;
this.initialHeight = initialHeight;
this.iframeCode = iframeCode;
this.frame = null;
this.timeInterval= 200;
this.appendTo = appendTo || false;
// initialize function for object
this.init = function(){
this.createFrame();
this.addFrameContent(this.iframeCode);
};
// Create the frame
this.createFrame = function(){
var htmlCode = "<"+"iframe src=\"\" allowtransparency=\"true\" frameborder=\"0\" name=\""+this.formId+"\" id=\""+this.formId+"\" style=\"width:100%; height:"+this.initialHeight+"px; border:none;\" scrolling=\"no\">";
if(this.appendTo === false){
document.write(htmlCode);
}else{
var tmp = document.createElement('div');
tmp.innerHTML = htmlCode;
var a = this.appendTo;
document.getElementById(a).appendChild(tmp.firstChild);
}
// also get the frame for future use.
this.frame = document.getElementById(this.formId);
// set the time on the on load event of the frame
this.addEvent(this.frame, 'load', this.bindMethod(this.setTimer, this));
};
// add event function for different browsers
this.addEvent = function( obj, type, fn ) {
if ( obj.attachEvent ) {
obj["e"+type+fn] = fn;
obj[type+fn] = function() { obj["e"+type+fn]( window.event ); };
obj.attachEvent( "on"+type, obj[type+fn] );
}
else{
obj.addEventListener( type, fn, false );
}
};
this.addFrameContent = function (string){
string = string.replace(new RegExp('src\\=\\"[^"]*captcha.php\"><\/scr'+'ipt>', 'gim'), 'src="http://api.recaptcha.net/js/recaptcha_ajax.js"><'+'div id="recaptcha_div"><'+'/div>'+
'<'+'style>#recaptcha_logo{ display:none;} #recaptcha_tagline{display:none;} #recaptcha_table{border:none !important;} .recaptchatable .recaptcha_image_cell, #recaptcha_table{ background-color:transparent !important; } <'+'/style>'+
'<'+'script defer="defer"> window.onload = function(){ Recaptcha.create("6Ld9UAgAAAAAAMon8zjt30tEZiGQZ4IIuWXLt1ky", "recaptcha_div", {theme: "clean",tabindex: 0,callback: function (){'+
'if (document.getElementById("uword")) { document.getElementById("uword").parentNode.removeChild(document.getElementById("uword")); } if (window["validate"] !== undefined) { if (document.getElementById("recaptcha_response_field")){ document.getElementById("recaptcha_response_field").onblur = function(){ validate(document.getElementById("recaptcha_response_field"), "Required"); } } } if (document.getElementById("recaptcha_response_field")){ document.getElementsByName("recaptcha_challenge_field")[0].setAttribute("name", "anum"); } if (document.getElementById("recaptcha_response_field")){ document.getElementsByName("recaptcha_response_field")[0].setAttribute("name", "qCap"); }}})'+
' }<'+'/script>');
string = string.replace(/(type="text\/javascript">)\s+(validate\(\"[^"]*"\);)/, '$1 jTime = setInterval(function(){if("validate" in window){$2clearTimeout(jTime);}}, 1000);');
var frameDocument = (this.frame.contentWindow) ? this.frame.contentWindow : (this.frame.contentDocument.document) ? this.frame.contentDocument.document : this.frame.contentDocument;
frameDocument.document.open();
frameDocument.document.write(string);
setTimeout( function(){
frameDocument.document.close();
try{
if('JotFormFrameLoaded' in window){
JotFormFrameLoaded();
}
}catch(e){}
},200);
};
this.setTimer = function(){
var self = this;
this.interval = setTimeout(function(){self.changeHeight();},this.timeInterval);
};
this.changeHeight = function (){
var actualHeight = this.getBodyHeight();
var currentHeight = this.getViewPortHeight();
if(actualHeight === undefined){
this.frame.style.height = "100%";
if(!this.frame.style.minHeight){
this.frame.style.minHeight = "300px";
}
}else if (Math.abs(actualHeight - currentHeight) > 18){
this.frame.style.height = (actualHeight)+"px";
}
this.setTimer();
};
this.bindMethod = function(method, scope) {
return function() {
method.apply(scope,arguments);
};
};
this.getBodyHeight = function (){
var height;
var scrollHeight;
var offsetHeight;
try{ // Prevent IE from throw errors
if (this.frame.contentWindow.document.height){
height = this.frame.contentWindow.document.height;
//Emre: to prevent "iframe height" problem (61059)
if (this.frame.contentWindow.document.body.scrollHeight){
height = scrollHeight = this.frame.contentWindow.document.body.scrollHeight;
}
if (this.frame.contentWindow.document.body.offsetHeight){
height = offsetHeight = this.frame.contentWindow.document.body.offsetHeight;
}
} else if (this.frame.contentWindow.document.body){
if (this.frame.contentWindow.document.body.scrollHeight){
height = scrollHeight = this.frame.contentWindow.document.body.scrollHeight;
}
if (this.frame.contentWindow.document.body.offsetHeight){
height = offsetHeight = this.frame.contentWindow.document.body.offsetHeight;
}
if (scrollHeight && offsetHeight){
height = Math.max(scrollHeight, offsetHeight);
}
}
}catch(e){ }
return height;
};
this.getViewPortHeight = function(){
var height = 0;
try{ // Prevent IE from throw errors
if (this.frame.contentWindow.window.innerHeight)
{
height = this.frame.contentWindow.window.innerHeight - 18;
}
else if ((this.frame.contentWindow.document.documentElement) &&
(this.frame.contentWindow.document.documentElement.clientHeight))
{
height = this.frame.contentWindow.document.documentElement.clientHeight;
}
else if ((this.frame.contentWindow.document.body) &&
(this.frame.contentWindow.document.body.clientHeight))
{
height = this.frame.contentWindow.document.body.clientHeight;
}
}catch(e){ }
return height;
};
this.init();
}
FrameBuilder.get = [];
var i2060919205 = new FrameBuilder("2060919205", false, "", "\n\n\n\n\nForm<\/title>\n<link href=\"http:\/\/max.jotfor.ms\/min\/g=formCss?3.0.2435\" rel=\"stylesheet\" type=\"text\/css\" \/>\n<style type=\"text\/css\">\n .form-label{\n width:150px !important;\n }\n .form-label-left{\n width:150px !important;\n }\n .form-line{\n padding:10px;\n }\n .form-label-right{\n width:150px !important;\n }\n body, html{\n margin:0;\n padding:0;\n background:false;\n }\n\n .form-all{\n margin:0px auto;\n padding-top:0px;\n width:740px;\n color:Black !important;\n font-family:Arial;\n font-size:10px;\n }\n<\/style>\n\n<script src=\"http:\/\/max.jotfor.ms\/min\/g=jotform?3.0.2435\" type=\"text\/javascript\"><\/script>\n<script type=\"text\/javascript\">\n var jsTime = setInterval(function(){try{\n JotForm.jsForm = true;\n\n JotForm.init(function(){\n $('input_3').hint('ex: myname@example.com');\n });\n\n clearInterval(jsTime);\n }catch(e){}}, 1000);\n<\/script>\n<\/head>\n<body>\n<form class=\"jotform-form\" action=\"http:\/\/submit.jotform.com\/submit.php\" method=\"post\" name=\"form_2060919205\" id=\"2060919205\" accept-charset=\"utf-8\">\n <input type=\"hidden\" name=\"formID\" value=\"2060919205\" \/>\n <div class=\"form-all\">\n <ul class=\"form-section\">\n <li id=\"cid_27\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_27\" class=\"form-header\">\n Fast Start Physician Contact Form\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_1\">\n <label class=\"form-label-top\" id=\"label_1\" for=\"input_1\">\n Full Name<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_1\" class=\"form-input-wide\"><span class=\"form-sub-label-container\"><input class=\"form-textbox validate[required]\" type=\"text\" size=\"10\" name=\"q1_fullName[first]\" id=\"first_1\" \/>\n <label class=\"form-sub-label\" for=\"first_1\" id=\"sublabel_first\"> First Name <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox validate[required]\" type=\"text\" size=\"15\" name=\"q1_fullName[last]\" id=\"last_1\" \/>\n <label class=\"form-sub-label\" for=\"last_1\" id=\"sublabel_last\"> Last Name <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_12\">\n <label class=\"form-label-top\" id=\"label_12\" for=\"input_12\">\n Phone Number<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_12\" class=\"form-input-wide\"><span class=\"form-sub-label-container\"><input class=\"form-textbox validate[required]\" type=\"tel\" name=\"q12_phoneNumber12[area]\" id=\"input_12_area\" size=\"3\">\n -\n <label class=\"form-sub-label\" for=\"input_12_area\" id=\"sublabel_area\"> Area Code <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox validate[required]\" type=\"tel\" name=\"q12_phoneNumber12[phone]\" id=\"input_12_phone\" size=\"8\">\n <label class=\"form-sub-label\" for=\"input_12_phone\" id=\"sublabel_phone\"> Phone Number <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_6\">\n <label class=\"form-label-top\" id=\"label_6\" for=\"input_6\">\n City<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_6\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_6\" name=\"q6_city\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column form-line-column-clear\" id=\"id_3\">\n <label class=\"form-label-top\" id=\"label_3\" for=\"input_3\">\n E-mail<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_3\" class=\"form-input-wide\">\n <input type=\"email\" class=\"form-textbox validate[required, Email]\" id=\"input_3\" name=\"q3_email\" size=\"30\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_5\">\n <label class=\"form-label-top\" id=\"label_5\" for=\"input_5\">\n State<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_5\" class=\"form-input-wide\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_5\" name=\"q5_state5\">\n <option> <\/option>\n <option value=\"Alabama\"> Alabama <\/option>\n <option value=\"Alaska\"> Alaska <\/option>\n <option value=\"Arizona\"> Arizona <\/option>\n <option value=\"Arkansas\"> Arkansas <\/option>\n <option value=\"California\"> California <\/option>\n <option value=\"Colorado\"> Colorado <\/option>\n <option value=\"Connecticut\"> Connecticut <\/option>\n <option value=\"District of Columbia\"> District of Columbia <\/option>\n <option value=\"Delaware\"> Delaware <\/option>\n <option value=\"Florida\"> Florida <\/option>\n <option value=\"Georgia\"> Georgia <\/option>\n <option value=\"Hawaii\"> Hawaii <\/option>\n <option value=\"Idaho\"> Idaho <\/option>\n <option value=\"Illinois\"> Illinois <\/option>\n <option value=\"Indiana\"> Indiana <\/option>\n <option value=\"Iowa\"> Iowa <\/option>\n <option value=\"Kansas\"> Kansas <\/option>\n <option value=\"Kentucky\"> Kentucky <\/option>\n <option value=\"Louisiana\"> Louisiana <\/option>\n <option value=\"Maine\"> Maine <\/option>\n <option value=\"Maryland\"> Maryland <\/option>\n <option value=\"Massachusetts\"> Massachusetts <\/option>\n <option value=\"Michigan\"> Michigan <\/option>\n <option value=\"Minnesota\"> Minnesota <\/option>\n <option value=\"Mississippi\"> Mississippi <\/option>\n <option value=\"Missouri\"> Missouri <\/option>\n <option value=\"Montana\"> Montana <\/option>\n <option value=\"Nebraska\"> Nebraska <\/option>\n <option value=\"Nevada\"> Nevada <\/option>\n <option value=\"New Hampshire\"> New Hampshire <\/option>\n <option value=\"New Jersey\"> New Jersey <\/option>\n <option value=\"New Mexico\"> New Mexico <\/option>\n <option value=\"New York\"> New York <\/option>\n <option value=\"North Carolina\"> North Carolina <\/option>\n <option value=\"North Dakota\"> North Dakota <\/option>\n <option value=\"Ohio\"> Ohio <\/option>\n <option value=\"Oklahoma\"> Oklahoma <\/option>\n <option value=\"Oregon\"> Oregon <\/option>\n <option value=\"Pennsylvania\"> Pennsylvania <\/option>\n <option value=\"Rhode Island\"> Rhode Island <\/option>\n <option value=\"South Carolina\"> South Carolina <\/option>\n <option value=\"South Dakota\"> South Dakota <\/option>\n <option value=\"Tennessee\"> Tennessee <\/option>\n <option value=\"Texas\"> Texas <\/option>\n <option value=\"Utah\"> Utah <\/option>\n <option value=\"Vermont\"> Vermont <\/option>\n <option value=\"Virginia\"> Virginia <\/option>\n <option value=\"Washington\"> Washington <\/option>\n <option value=\"West Virginia\"> West Virginia <\/option>\n <option value=\"Wisconsin\"> Wisconsin <\/option>\n <option value=\"Wyoming\"> Wyoming <\/option>\n <option value=\"Alberta\"> Alberta <\/option>\n <option value=\"British Columbia\"> British Columbia <\/option>\n <option value=\"Manitoba\"> Manitoba <\/option>\n <option value=\"New Brunswick\"> New Brunswick <\/option>\n <option value=\"Newfoundland\"> Newfoundland <\/option>\n <option value=\"Northwest Territories\"> Northwest Territories <\/option>\n <option value=\"Nova Scotia\"> Nova Scotia <\/option>\n <option value=\"Nunavut\"> Nunavut <\/option>\n <option value=\"Ontario\"> Ontario <\/option>\n <option value=\"Prince Edward Island\"> Prince Edward Island <\/option>\n <option value=\"Quebec\"> Quebec <\/option>\n <option value=\"Saskatchewan\"> Saskatchewan <\/option>\n <option value=\"Yukon\"> Yukon <\/option>\n <option value=\"Alabama\"> Alabama <\/option>\n <option value=\"Alaska\"> Alaska <\/option>\n <option value=\"Arizona\"> Arizona <\/option>\n <option value=\"Arkansas\"> Arkansas <\/option>\n <option value=\"California\"> California <\/option>\n <option value=\"Colorado\"> Colorado <\/option>\n <option value=\"Connecticut\"> Connecticut <\/option>\n <option value=\"District of Columbia\"> District of Columbia <\/option>\n <option value=\"Delaware\"> Delaware <\/option>\n <option value=\"Florida\"> Florida <\/option>\n <option value=\"Georgia\"> Georgia <\/option>\n <option value=\"Hawaii\"> Hawaii <\/option>\n <option value=\"Idaho\"> Idaho <\/option>\n <option value=\"Illinois\"> Illinois <\/option>\n <option value=\"Indiana\"> Indiana <\/option>\n <option value=\"Iowa\"> Iowa <\/option>\n <option value=\"Kansas\"> Kansas <\/option>\n <option value=\"Kentucky\"> Kentucky <\/option>\n <option value=\"Louisiana\"> Louisiana <\/option>\n <option value=\"Maine\"> Maine <\/option>\n <option value=\"Maryland\"> Maryland <\/option>\n <option value=\"Massachusetts\"> Massachusetts <\/option>\n <option value=\"Michigan\"> Michigan <\/option>\n <option value=\"Minnesota\"> Minnesota <\/option>\n <option value=\"Mississippi\"> Mississippi <\/option>\n <option value=\"Missouri\"> Missouri <\/option>\n <option value=\"Montana\"> Montana <\/option>\n <option value=\"Nebraska\"> Nebraska <\/option>\n <option value=\"Nevada\"> Nevada <\/option>\n <option value=\"New Hampshire\"> New Hampshire <\/option>\n <option value=\"New Jersey\"> New Jersey <\/option>\n <option value=\"New Mexico\"> New Mexico <\/option>\n <option value=\"New York\"> New York <\/option>\n <option value=\"North Carolina\"> North Carolina <\/option>\n <option value=\"North Dakota\"> North Dakota <\/option>\n <option value=\"Ohio\"> Ohio <\/option>\n <option value=\"Oklahoma\"> Oklahoma <\/option>\n <option value=\"Oregon\"> Oregon <\/option>\n <option value=\"Pennsylvania\"> Pennsylvania <\/option>\n <option value=\"Rhode Island\"> Rhode Island <\/option>\n <option value=\"South Carolina\"> South Carolina <\/option>\n <option value=\"South Dakota\"> South Dakota <\/option>\n <option value=\"Tennessee\"> Tennessee <\/option>\n <option value=\"Texas\"> Texas <\/option>\n <option value=\"Utah\"> Utah <\/option>\n <option value=\"Vermont\"> Vermont <\/option>\n <option value=\"Virginia\"> Virginia <\/option>\n <option value=\"Washington\"> Washington <\/option>\n <option value=\"West Virginia\"> West Virginia <\/option>\n <option value=\"Wisconsin\"> Wisconsin <\/option>\n <option value=\"Wyoming\"> Wyoming <\/option>\n <option value=\"Alberta\"> Alberta <\/option>\n <option value=\"British Columbia\"> British Columbia <\/option>\n <option value=\"Manitoba\"> Manitoba <\/option>\n <option value=\"New Brunswick\"> New Brunswick <\/option>\n <option value=\"Newfoundland\"> Newfoundland <\/option>\n <option value=\"Northwest Territories\"> Northwest Territories <\/option>\n <option value=\"Nova Scotia\"> Nova Scotia <\/option>\n <option value=\"Nunavut\"> Nunavut <\/option>\n <option value=\"Ontario\"> Ontario <\/option>\n <option value=\"Prince Edward Island\"> Prince Edward Island <\/option>\n <option value=\"Quebec\"> Quebec <\/option>\n <option value=\"Saskatchewan\"> Saskatchewan <\/option>\n <option value=\"Yukon\"> Yukon <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column form-line-column-clear\" id=\"id_9\">\n <label class=\"form-label-top\" id=\"label_9\" for=\"input_9\"> Comments, Questions, Etc., You Want To Ask Us. <\/label>\n <div id=\"cid_9\" class=\"form-input-wide\">\n <textarea id=\"input_9\" class=\"form-textarea\" name=\"q9_commentsQuestions\" cols=\"60\" rows=\"4\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_7\">\n <label class=\"form-label-top\" id=\"label_7\" for=\"input_7\">\n How Did You Learn About Us?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_7\" class=\"form-input-wide\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_7\" name=\"q7_howDid7\">\n <option> <\/option>\n <option value=\"Google Search.\"> Google Search. <\/option>\n <option value=\"Physician Referral.\"> Physician Referral. <\/option>\n <option value=\"A Patient Told Me About You.\"> A Patient Told Me About You. <\/option>\n <option value=\"You Tube.\"> You Tube. <\/option>\n <option value=\"Linked In.\"> Linked In. <\/option>\n <option value=\"Facebook.\"> Facebook. <\/option>\n <option value=\"AAPP\/SIMPD.\"> AAPP\/SIMPD. <\/option>\n <option value=\"Concierge Medicine Today.\"> Concierge Medicine Today. <\/option>\n <option value=\"Other\"> Other <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_10\">\n <label class=\"form-label-top\" id=\"label_10\" for=\"input_10\"> If Other, Please List Here. <\/label>\n <div id=\"cid_10\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_10\" name=\"q10_ifOther\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li id=\"cid_29\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_29\" class=\"form-header\">\n Practice Information\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_16\">\n <label class=\"form-label-top\" id=\"label_16\" for=\"input_16\">\n Address<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_16\" class=\"form-input-wide\">\n <table summary=\"\" class=\"form-address-table\" border=\"0\" cellpadding=\"0\" cellspacing=\"0\">\n <tr>\n <td colspan=\"2\"><span class=\"form-sub-label-container\"><input class=\"form-textbox validate[required] form-address-line\" type=\"text\" name=\"q16_address16[addr_line1]\" id=\"input_16_addr_line1\" \/>\n <label class=\"form-sub-label\" for=\"input_16_addr_line1\" id=\"sublabel_addr_line1\"> Street Address <\/label><\/span>\n <\/td>\n <\/tr>\n <tr>\n <td colspan=\"2\"><span class=\"form-sub-label-container\"><input class=\"form-textbox form-address-line\" type=\"text\" name=\"q16_address16[addr_line2]\" id=\"input_16_addr_line2\" size=\"46\" \/>\n <label class=\"form-sub-label\" for=\"input_16_addr_line2\" id=\"sublabel_addr_line2\"> Street Address Line 2 <\/label><\/span>\n <\/td>\n <\/tr>\n <tr>\n <td width=\"50%\"><span class=\"form-sub-label-container\"><input class=\"form-textbox validate[required] form-address-city\" type=\"text\" name=\"q16_address16[city]\" id=\"input_16_city\" size=\"21\" \/>\n <label class=\"form-sub-label\" for=\"input_16_city\" id=\"sublabel_city\"> City <\/label><\/span>\n <\/td>\n <td><span class=\"form-sub-label-container\"><input class=\"form-textbox validate[required] form-address-state\" type=\"text\" name=\"q16_address16[state]\" id=\"input_16_state\" size=\"22\" \/>\n <label class=\"form-sub-label\" for=\"input_16_state\" id=\"sublabel_state\"> State \/ Province <\/label><\/span>\n <\/td>\n <\/tr>\n <tr>\n <td width=\"50%\"><span class=\"form-sub-label-container\"><input class=\"form-textbox validate[required] form-address-postal\" type=\"text\" name=\"q16_address16[postal]\" id=\"input_16_postal\" size=\"10\" \/>\n <label class=\"form-sub-label\" for=\"input_16_postal\" id=\"sublabel_postal\"> Postal \/ Zip Code <\/label><\/span>\n <\/td>\n <td><span class=\"form-sub-label-container\"><select class=\"form-dropdown validate[required] form-address-country\" name=\"q16_address16[country]\" id=\"input_16_country\">\n <option selected> Please Select <\/option>\n <option value=\"United States\"> United States <\/option>\n <option value=\"Abkhazia\"> Abkhazia <\/option>\n <option value=\"Afghanistan\"> Afghanistan <\/option>\n <option value=\"Albania\"> Albania <\/option>\n <option value=\"Algeria\"> Algeria <\/option>\n <option value=\"American Samoa\"> American Samoa <\/option>\n <option value=\"Andorra\"> Andorra <\/option>\n <option value=\"Angola\"> Angola <\/option>\n <option value=\"Anguilla\"> Anguilla <\/option>\n <option value=\"Antigua and Barbuda\"> Antigua and Barbuda <\/option>\n <option value=\"Argentina\"> Argentina <\/option>\n <option value=\"Armenia\"> Armenia <\/option>\n <option value=\"Aruba\"> Aruba <\/option>\n <option value=\"Australia\"> Australia <\/option>\n <option value=\"Austria\"> Austria <\/option>\n <option value=\"Azerbaijan\"> Azerbaijan <\/option>\n <option value=\"The Bahamas\"> The Bahamas <\/option>\n <option value=\"Bahrain\"> Bahrain <\/option>\n <option value=\"Bangladesh\"> Bangladesh <\/option>\n <option value=\"Barbados\"> Barbados <\/option>\n <option value=\"Belarus\"> Belarus <\/option>\n <option value=\"Belgium\"> Belgium <\/option>\n <option value=\"Belize\"> Belize <\/option>\n <option value=\"Benin\"> Benin <\/option>\n <option value=\"Bermuda\"> Bermuda <\/option>\n <option value=\"Bhutan\"> Bhutan <\/option>\n <option value=\"Bolivia\"> Bolivia <\/option>\n <option value=\"Bosnia and Herzegovina\"> Bosnia and Herzegovina <\/option>\n <option value=\"Botswana\"> Botswana <\/option>\n <option value=\"Brazil\"> Brazil <\/option>\n <option value=\"Brunei\"> Brunei <\/option>\n <option value=\"Bulgaria\"> Bulgaria <\/option>\n <option value=\"Burkina Faso\"> Burkina Faso <\/option>\n <option value=\"Burundi\"> Burundi <\/option>\n <option value=\"Cambodia\"> Cambodia <\/option>\n <option value=\"Cameroon\"> Cameroon <\/option>\n <option value=\"Canada\"> Canada <\/option>\n <option value=\"Cape Verde\"> Cape Verde <\/option>\n <option value=\"Cayman Islands\"> Cayman Islands <\/option>\n <option value=\"Central African Republic\"> Central African Republic <\/option>\n <option value=\"Chad\"> Chad <\/option>\n <option value=\"Chile\"> Chile <\/option>\n <option value=\"People's Republic of China\"> People's Republic of China <\/option>\n <option value=\"Republic of China\"> Republic of China <\/option>\n <option value=\"Christmas Island\"> Christmas Island <\/option>\n <option value=\"Cocos (Keeling) Islands\"> Cocos (Keeling) Islands <\/option>\n <option value=\"Colombia\"> Colombia <\/option>\n <option value=\"Comoros\"> Comoros <\/option>\n <option value=\"Congo\"> Congo <\/option>\n <option value=\"Cook Islands\"> Cook Islands <\/option>\n <option value=\"Costa Rica\"> Costa Rica <\/option>\n <option value=\"Cote d'Ivoire\"> Cote d'Ivoire <\/option>\n <option value=\"Croatia\"> Croatia <\/option>\n <option value=\"Cuba\"> Cuba <\/option>\n <option value=\"Cyprus\"> Cyprus <\/option>\n <option value=\"Czech Republic\"> Czech Republic <\/option>\n <option value=\"Denmark\"> Denmark <\/option>\n <option value=\"Djibouti\"> Djibouti <\/option>\n <option value=\"Dominica\"> Dominica <\/option>\n <option value=\"Dominican Republic\"> Dominican Republic <\/option>\n <option value=\"Ecuador\"> Ecuador <\/option>\n <option value=\"Egypt\"> Egypt <\/option>\n <option value=\"El Salvador\"> El Salvador <\/option>\n <option value=\"Equatorial Guinea\"> Equatorial Guinea <\/option>\n <option value=\"Eritrea\"> Eritrea <\/option>\n <option value=\"Estonia\"> Estonia <\/option>\n <option value=\"Ethiopia\"> Ethiopia <\/option>\n <option value=\"Falkland Islands\"> Falkland Islands <\/option>\n <option value=\"Faroe Islands\"> Faroe Islands <\/option>\n <option value=\"Fiji\"> Fiji <\/option>\n <option value=\"Finland\"> Finland <\/option>\n <option value=\"France\"> France <\/option>\n <option value=\"French Polynesia\"> French Polynesia <\/option>\n <option value=\"Gabon\"> Gabon <\/option>\n <option value=\"The Gambia\"> The Gambia <\/option>\n <option value=\"Georgia\"> Georgia <\/option>\n <option value=\"Germany\"> Germany <\/option>\n <option value=\"Ghana\"> Ghana <\/option>\n <option value=\"Gibraltar\"> Gibraltar <\/option>\n <option value=\"Greece\"> Greece <\/option>\n <option value=\"Greenland\"> Greenland <\/option>\n <option value=\"Grenada\"> Grenada <\/option>\n <option value=\"Guadeloupe\"> Guadeloupe <\/option>\n <option value=\"Guam\"> Guam <\/option>\n <option value=\"Guatemala\"> Guatemala <\/option>\n <option value=\"Guernsey\"> Guernsey <\/option>\n <option value=\"Guinea\"> Guinea <\/option>\n <option value=\"Guinea-Bissau\"> Guinea-Bissau <\/option>\n <option value=\"Guyana\"> Guyana <\/option>\n <option value=\"Haiti\"> Haiti <\/option>\n <option value=\"Honduras\"> Honduras <\/option>\n <option value=\"Hong Kong\"> Hong Kong <\/option>\n <option value=\"Hungary\"> Hungary <\/option>\n <option value=\"Iceland\"> Iceland <\/option>\n <option value=\"India\"> India <\/option>\n <option value=\"Indonesia\"> Indonesia <\/option>\n <option value=\"Iran\"> Iran <\/option>\n <option value=\"Iraq\"> Iraq <\/option>\n <option value=\"Ireland\"> Ireland <\/option>\n <option value=\"Israel\"> Israel <\/option>\n <option value=\"Italy\"> Italy <\/option>\n <option value=\"Jamaica\"> Jamaica <\/option>\n <option value=\"Japan\"> Japan <\/option>\n <option value=\"Jersey\"> Jersey <\/option>\n <option value=\"Jordan\"> Jordan <\/option>\n <option value=\"Kazakhstan\"> Kazakhstan <\/option>\n <option value=\"Kenya\"> Kenya <\/option>\n <option value=\"Kiribati\"> Kiribati <\/option>\n <option value=\"North Korea\"> North Korea <\/option>\n <option value=\"South Korea\"> South Korea <\/option>\n <option value=\"Kosovo\"> Kosovo <\/option>\n <option value=\"Kuwait\"> Kuwait <\/option>\n <option value=\"Kyrgyzstan\"> Kyrgyzstan <\/option>\n <option value=\"Laos\"> Laos <\/option>\n <option value=\"Latvia\"> Latvia <\/option>\n <option value=\"Lebanon\"> Lebanon <\/option>\n <option value=\"Lesotho\"> Lesotho <\/option>\n <option value=\"Liberia\"> Liberia <\/option>\n <option value=\"Libya\"> Libya <\/option>\n <option value=\"Liechtenstein\"> Liechtenstein <\/option>\n <option value=\"Lithuania\"> Lithuania <\/option>\n <option value=\"Luxembourg\"> Luxembourg <\/option>\n <option value=\"Macau\"> Macau <\/option>\n <option value=\"Macedonia\"> Macedonia <\/option>\n <option value=\"Madagascar\"> Madagascar <\/option>\n <option value=\"Malawi\"> Malawi <\/option>\n <option value=\"Malaysia\"> Malaysia <\/option>\n <option value=\"Maldives\"> Maldives <\/option>\n <option value=\"Mali\"> Mali <\/option>\n <option value=\"Malta\"> Malta <\/option>\n <option value=\"Marshall Islands\"> Marshall Islands <\/option>\n <option value=\"Martinique\"> Martinique <\/option>\n <option value=\"Mauritania\"> Mauritania <\/option>\n <option value=\"Mauritius\"> Mauritius <\/option>\n <option value=\"Mayotte\"> Mayotte <\/option>\n <option value=\"Mexico\"> Mexico <\/option>\n <option value=\"Micronesia\"> Micronesia <\/option>\n <option value=\"Moldova\"> Moldova <\/option>\n <option value=\"Monaco\"> Monaco <\/option>\n <option value=\"Mongolia\"> Mongolia <\/option>\n <option value=\"Montenegro\"> Montenegro <\/option>\n <option value=\"Montserrat\"> Montserrat <\/option>\n <option value=\"Morocco\"> Morocco <\/option>\n <option value=\"Mozambique\"> Mozambique <\/option>\n <option value=\"Myanmar\"> Myanmar <\/option>\n <option value=\"Nagorno-Karabakh\"> Nagorno-Karabakh <\/option>\n <option value=\"Namibia\"> Namibia <\/option>\n <option value=\"Nauru\"> Nauru <\/option>\n <option value=\"Nepal\"> Nepal <\/option>\n <option value=\"Netherlands\"> Netherlands <\/option>\n <option value=\"Netherlands Antilles\"> Netherlands Antilles <\/option>\n <option value=\"New Caledonia\"> New Caledonia <\/option>\n <option value=\"New Zealand\"> New Zealand <\/option>\n <option value=\"Nicaragua\"> Nicaragua <\/option>\n <option value=\"Niger\"> Niger <\/option>\n <option value=\"Nigeria\"> Nigeria <\/option>\n <option value=\"Niue\"> Niue <\/option>\n <option value=\"Norfolk Island\"> Norfolk Island <\/option>\n <option value=\"Turkish Republic of Northern Cyprus\"> Turkish Republic of Northern Cyprus <\/option>\n <option value=\"Northern Mariana\"> Northern Mariana <\/option>\n <option value=\"Norway\"> Norway <\/option>\n <option value=\"Oman\"> Oman <\/option>\n <option value=\"Pakistan\"> Pakistan <\/option>\n <option value=\"Palau\"> Palau <\/option>\n <option value=\"Palestine\"> Palestine <\/option>\n <option value=\"Panama\"> Panama <\/option>\n <option value=\"Papua New Guinea\"> Papua New Guinea <\/option>\n <option value=\"Paraguay\"> Paraguay <\/option>\n <option value=\"Peru\"> Peru <\/option>\n <option value=\"Philippines\"> Philippines <\/option>\n <option value=\"Pitcairn Islands\"> Pitcairn Islands <\/option>\n <option value=\"Poland\"> Poland <\/option>\n <option value=\"Portugal\"> Portugal <\/option>\n <option value=\"Puerto Rico\"> Puerto Rico <\/option>\n <option value=\"Qatar\"> Qatar <\/option>\n <option value=\"Romania\"> Romania <\/option>\n <option value=\"Russia\"> Russia <\/option>\n <option value=\"Rwanda\"> Rwanda <\/option>\n <option value=\"Saint Barthelemy\"> Saint Barthelemy <\/option>\n <option value=\"Saint Helena\"> Saint Helena <\/option>\n <option value=\"Saint Kitts and Nevis\"> Saint Kitts and Nevis <\/option>\n <option value=\"Saint Lucia\"> Saint Lucia <\/option>\n <option value=\"Saint Martin\"> Saint Martin <\/option>\n <option value=\"Saint Pierre and Miquelon\"> Saint Pierre and Miquelon <\/option>\n <option value=\"Saint Vincent and the Grenadines\"> Saint Vincent and the Grenadines <\/option>\n <option value=\"Samoa\"> Samoa <\/option>\n <option value=\"San Marino\"> San Marino <\/option>\n <option value=\"Sao Tome and Principe\"> Sao Tome and Principe <\/option>\n <option value=\"Saudi Arabia\"> Saudi Arabia <\/option>\n <option value=\"Senegal\"> Senegal <\/option>\n <option value=\"Serbia\"> Serbia <\/option>\n <option value=\"Seychelles\"> Seychelles <\/option>\n <option value=\"Sierra Leone\"> Sierra Leone <\/option>\n <option value=\"Singapore\"> Singapore <\/option>\n <option value=\"Slovakia\"> Slovakia <\/option>\n <option value=\"Slovenia\"> Slovenia <\/option>\n <option value=\"Solomon Islands\"> Solomon Islands <\/option>\n <option value=\"Somalia\"> Somalia <\/option>\n <option value=\"Somaliland\"> Somaliland <\/option>\n <option value=\"South Africa\"> South Africa <\/option>\n <option value=\"South Ossetia\"> South Ossetia <\/option>\n <option value=\"Spain\"> Spain <\/option>\n <option value=\"Sri Lanka\"> Sri Lanka <\/option>\n <option value=\"Sudan\"> Sudan <\/option>\n <option value=\"Suriname\"> Suriname <\/option>\n <option value=\"Svalbard\"> Svalbard <\/option>\n <option value=\"Swaziland\"> Swaziland <\/option>\n <option value=\"Sweden\"> Sweden <\/option>\n <option value=\"Switzerland\"> Switzerland <\/option>\n <option value=\"Syria\"> Syria <\/option>\n <option value=\"Taiwan\"> Taiwan <\/option>\n <option value=\"Tajikistan\"> Tajikistan <\/option>\n <option value=\"Tanzania\"> Tanzania <\/option>\n <option value=\"Thailand\"> Thailand <\/option>\n <option value=\"Timor-Leste\"> Timor-Leste <\/option>\n <option value=\"Togo\"> Togo <\/option>\n <option value=\"Tokelau\"> Tokelau <\/option>\n <option value=\"Tonga\"> Tonga <\/option>\n <option value=\"Transnistria Pridnestrovie\"> Transnistria Pridnestrovie <\/option>\n <option value=\"Trinidad and Tobago\"> Trinidad and Tobago <\/option>\n <option value=\"Tristan da Cunha\"> Tristan da Cunha <\/option>\n <option value=\"Tunisia\"> Tunisia <\/option>\n <option value=\"Turkey\"> Turkey <\/option>\n <option value=\"Turkmenistan\"> Turkmenistan <\/option>\n <option value=\"Turks and Caicos Islands\"> Turks and Caicos Islands <\/option>\n <option value=\"Tuvalu\"> Tuvalu <\/option>\n <option value=\"Uganda\"> Uganda <\/option>\n <option value=\"Ukraine\"> Ukraine <\/option>\n <option value=\"United Arab Emirates\"> United Arab Emirates <\/option>\n <option value=\"United Kingdom\"> United Kingdom <\/option>\n <option value=\"Uruguay\"> Uruguay <\/option>\n <option value=\"Uzbekistan\"> Uzbekistan <\/option>\n <option value=\"Vanuatu\"> Vanuatu <\/option>\n <option value=\"Vatican City\"> Vatican City <\/option>\n <option value=\"Venezuela\"> Venezuela <\/option>\n <option value=\"Vietnam\"> Vietnam <\/option>\n <option value=\"British Virgin Islands\"> British Virgin Islands <\/option>\n <option value=\"US Virgin Islands\"> US Virgin Islands <\/option>\n <option value=\"Wallis and Futuna\"> Wallis and Futuna <\/option>\n <option value=\"Western Sahara\"> Western Sahara <\/option>\n <option value=\"Yemen\"> Yemen <\/option>\n <option value=\"Zambia\"> Zambia <\/option>\n <option value=\"Zimbabwe\"> Zimbabwe <\/option>\n <option value=\"other\"> Other <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_16_country\" id=\"sublabel_country\"> Country <\/label><\/span>\n <\/td>\n <\/tr>\n <\/table>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_17\">\n <label class=\"form-label-top\" id=\"label_17\" for=\"input_17\"> Your Web Site Address <\/label>\n <div id=\"cid_17\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_17\" name=\"q17_yourWeb\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_18\">\n <label class=\"form-label-top\" id=\"label_18\" for=\"input_18\">\n How Many Patients Do You Need To Fill Your Concierge Medical Practice?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_18\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_18\" name=\"q18_howMany\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_19\">\n <label class=\"form-label-top\" id=\"label_19\" for=\"input_19\">\n How Soon Would You Like To Start?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_19\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_19\" name=\"q19_howSoon\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li id=\"cid_30\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_30\" class=\"form-header\">\n Describe Your Past Success(es) With Marketing & Trying To Recruit New or Former Patients Into Your Concierge Medical Practice.\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_20\">\n <label class=\"form-label-top\" id=\"label_20\" for=\"input_20\">\n Describe What Types of Marketing Programs You've Utilized In The Past To Recruit New or Former Patients & How Successful Were They.<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_20\" class=\"form-input-wide\">\n <textarea id=\"input_20\" class=\"form-textarea validate[required]\" name=\"q20_describeWhat\" cols=\"40\" rows=\"6\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_21\">\n <label class=\"form-label-top\" id=\"label_21\" for=\"input_21\">\n What Makes Your Practice Truly Unique From Other Physicians Around You?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_21\" class=\"form-input-wide\">\n <textarea id=\"input_21\" class=\"form-textarea validate[required]\" name=\"q21_whatMakes\" cols=\"40\" rows=\"6\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_22\">\n <label class=\"form-label-top\" id=\"label_22\" for=\"input_22\">\n How Many Years Have You Been Practicing Medicine In Your Current Community?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_22\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_22\" name=\"q22_howMany22\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li id=\"cid_28\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_28\" class=\"form-header\">\n Business Model or Type\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_23\">\n <label class=\"form-label-top\" id=\"label_23\" for=\"input_23\">\n How Many Years Have You Been Operating Business Within A Concierge Medicine Business Model?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_23\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_23\" name=\"q23_howMany23\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_24\">\n <label class=\"form-label-top\" id=\"label_24\" for=\"input_24\">\n How Many Patients Do Your Currently Have Who You Would Consider \"Concierge\" Patients?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_24\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_24\" name=\"q24_howMany24\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_25\">\n <label class=\"form-label-top\" id=\"label_25\" for=\"input_25\">\n What Type of Concierge Medicine Business Model Is Your Practice?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_25\" class=\"form-input-wide\">\n <div class=\"form-single-column\"><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_25_0\" name=\"q25_whatType[]\" value=\"Fee For Care\" \/>\n <label for=\"input_25_0\"> Fee For Care <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_25_1\" name=\"q25_whatType[]\" value=\"Hybrid\" \/>\n <label for=\"input_25_1\"> Hybrid <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_25_2\" name=\"q25_whatType[]\" value=\"Other\" \/>\n <label for=\"input_25_2\"> Other <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_26\">\n <label class=\"form-label-top\" id=\"label_26\" for=\"input_26\"> If You Checked Other, Please Describe Here. <\/label>\n <div id=\"cid_26\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_26\" name=\"q26_ifYou\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li id=\"cid_15\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_15\" class=\"form-header\">\n What Area of Marketing Expertise Are You Most Interested In?\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_11\">\n <label class=\"form-label-top\" id=\"label_11\" for=\"input_11\">\n You May Check More Than One.<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_11\" class=\"form-input-wide\">\n <div class=\"form-single-column\"><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_11_0\" name=\"q11_youMay[]\" value=\"I NEED A MARKETING COACH :: Marketing\/Advertising Training anEducation For Concierge Physicians\" \/>\n <label for=\"input_11_0\"> I NEED A MARKETING COACH :: Marketing\/Advertising Training anEducation For Concierge Physicians <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_11_1\" name=\"q11_youMay[]\" value=\"MICRO-SITE DEVELOPMENT :: Facebook, Twitter, One-Page Web Site Homepage, Etc.\" 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<\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_11_5\" name=\"q11_youMay[]\" value=\"1 to 20 MILE RADIUS :: Top of Mind Awareness Campaign\" \/>\n <label for=\"input_11_5\"> 1 to 20 MILE RADIUS :: Top of Mind Awareness Campaign <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_11_6\" name=\"q11_youMay[]\" value=\"ONLINE DIRECTORIES :: Search Engine Optimization\" \/>\n <label for=\"input_11_6\"> ONLINE DIRECTORIES :: Search Engine Optimization <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_11_7\" name=\"q11_youMay[]\" value=\"PRINT, TV and RADIO :: Direct To Consumer Advertising [DTC]\" \/>\n <label for=\"input_11_7\"> PRINT, TV and RADIO :: Direct To Consumer Advertising [DTC] <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_11_8\" name=\"q11_youMay[]\" value=\"DIRECT MAIL :: Postcards, Letters, Coupons, Etc.\" \/>\n <label for=\"input_11_8\"> DIRECT MAIL :: Postcards, Letters, Coupons, Etc. <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_11_9\" name=\"q11_youMay[]\" value=\"GOOGLE :: Get Found On Google\" \/>\n <label for=\"input_11_9\"> GOOGLE :: Get Found On Google <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_11_10\" name=\"q11_youMay[]\" value=\"TWITTER :: Account Management and Content Creation\" \/>\n <label for=\"input_11_10\"> TWITTER :: Account Management and Content Creation <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_11_11\" name=\"q11_youMay[]\" value=\"FACEBOOK :: Account Management and Content Creation\" \/>\n <label for=\"input_11_11\"> FACEBOOK :: Account Management and Content Creation <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_11_12\" name=\"q11_youMay[]\" value=\"BRONZE LEVEL :: I Want To Learn More\" \/>\n <label for=\"input_11_12\"> BRONZE LEVEL :: I Want To Learn More <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_11_13\" name=\"q11_youMay[]\" value=\"GREEN LEVEL :: I Want To Learn More\" \/>\n <label for=\"input_11_13\"> GREEN LEVEL :: I Want To Learn More <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_11_14\" name=\"q11_youMay[]\" value=\"GOLD LEVEL :: I Want To Learn More\" \/>\n <label for=\"input_11_14\"> GOLD LEVEL :: I Want To Learn More <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_11_15\" name=\"q11_youMay[]\" value=\"Please Email or Mail Me A Copy of Elite MD's Service Brochure & Fast Start Check-In\" \/>\n <label for=\"input_11_15\"> Please Email or Mail Me A Copy of Elite MD's Service Brochure & Fast Start Check-In <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_11_16\" name=\"q11_youMay[]\" value=\"I'd Like To Receive Marketing Tips & News\" \/>\n <label for=\"input_11_16\"> I'd Like To Receive Marketing Tips & News <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_2\">\n <div id=\"cid_2\" class=\"form-input-wide\">\n <div style=\"text-align:left\" class=\"form-buttons-wrapper\">\n <button id=\"input_2\" type=\"submit\" class=\"form-submit-button\">\n Submit\n <\/button>\n <\/div>\n <\/div>\n <\/li>\n <li style=\"display:none\">\n Should be Empty:\n <input type=\"text\" name=\"website\" value=\"\" \/>\n <\/li>\n <\/ul>\n <\/div>\n <input type=\"hidden\" id=\"simple_spc\" name=\"simple_spc\" value=\"2060919205\" \/>\n <script type=\"text\/javascript\">\n document.getElementById(\"si\" + \"mple\" + \"_spc\").value = \"2060919205-2060919205\";\n <\/script>\n<\/form><\/body>\n<\/html>\n");