document.writeln('<form action="http:\/\/www.jays-holistics.co.uk\/cgi-bin\/jhc&#111;&#110;&#116;&#97;&#99;&#116;.cgi" method="post" name="form1" onSubmit="VF_form1();return false;">\r\n                          <input type="hidden" name="_browser_out" value="contactchk.htm">\r\n                          <table width="90%" border="0" align="center" cellpadding="5" cellspacing="0" class="text2form">\r\n                            <tr>\r\n                              <td>Your name*<\/td>\r\n                              <td><select name="Title">\r\n                                  <option>Mrs<\/option>\r\n                                  <option>Mr<\/option>\r\n                                  <option selected>Ms<\/option>\r\n                                  <option>Miss<\/option>\r\n                                <\/select>\r\n                                  <input name="Name" type="text" size="24"><\/td>\r\n                            <\/tr>\r\n                            <tr>\r\n                              <td>E-mail address*<\/td>\r\n                              <td><input type="text" name="From"><\/td>\r\n                            <\/tr>\r\n                            <tr>\r\n                              <td>Nearest Town<\/td>\r\n                              <td><input type="text" name="location">\r\n                              <\/td>\r\n                            <\/tr>\r\n                            <tr>\r\n                              <td>Postcode<\/td>\r\n                              <td><input type="text" name="postcode">\r\n                              <\/td>\r\n                            <\/tr>\r\n                            <tr>\r\n                              <td>Contact Phone Number<\/td>\r\n                              <td><input type="text" name="Telephone"><\/td>\r\n                            <\/tr>\r\n                            <tr>\r\n                              <td>Mobile<\/td>\r\n                              <td><input type="text" name="Mobile"><\/td>\r\n                            <\/tr>\r\n                            <tr>\r\n                              <td><div align="left">Which therapy or therapies<br>\r\n                                are\r\n                                  you interested in?<br>\r\n          (please select at least one) * <\/div><\/td>\r\n                              <td><p>\r\n                                  <input type="checkbox" vfgroup="show" name="checkbox" value="Reflexology. ">\r\n          Reflexology<br>\r\n          <input type="checkbox" vfgroup="show" name="checkbox2" value="Massage. ">\r\n          Massage<br>\r\n          <input type="checkbox" vfgroup="show" name="checkbox3" value="Hydrotherm. ">\r\n          Hydrotherm Massage <br>\r\n          <input type="checkbox" vfgroup="show" name="checkbox4" value="Aromatherapy. ">\r\n          Aromatherapy Massage<br>\r\n          <input type="checkbox" vfgroup="show" name="checkbox5" value="Maternity Massage. ">\r\n          Maternity Massage <br>\r\n          <input type="checkbox" vfgroup="show" name="checkbox6" value="Maternity Reflexology. ">\r\n          Maternity Reflexology <br>\r\n          <input type="checkbox" vfgroup="show" name="checkbox7" value="On-site Massage.">\r\n          On-site Massage <\/p><\/td>\r\n                            <\/tr>\r\n                            <tr>\r\n                              <td colspan="2"><div align="center"><br>\r\n          If you have any other comments, queries or information please enter\r\n              them in the box below.<\/div><\/td>\r\n                            <\/tr>\r\n                            <tr>\r\n                              <td colspan="2"><div align="center">\r\n                                  <textarea name="info" cols="50" rows="3"><\/textarea>\r\n                              <\/div><\/td>\r\n                            <\/tr>\r\n                            <tr>\r\n                              <td>How did you discover this website*<\/td>\r\n                              <td><p>\r\n                                  <select name="found">\r\n                                    <option selected>Please Choose:\r\n                                    <option>Referral\r\n                                    <option>Leaflet\r\n                                    <option>Business Card\r\n                                    <option>Sticker \r\n                                    <option>Google\r\n                                    <option>AltaVista\r\n                                    <option>Ask Jeeves\r\n                                    <option>Yahoo\r\n                                    <option>Search Engine\r\n                                    <option>Other\r\n                                <\/select>\r\n                              <\/p><\/td>\r\n                            <\/tr>\r\n                            <tr>\r\n                              <td colspan="2">&nbsp;<\/td>\r\n                            <\/tr>\r\n                            <tr>\r\n                              <td colspan="2"><div align="center">\r\n                                  <input name="Submit" type="submit" class="button" onClick="MM_popupMsg(\'Click OK &amp; please wait for confirmation.\')" value="Submit">\r\n                                  <img src="..\/shim.gif" width="100" height="1">\r\n                                  <input name="Reset" type="reset" class="button" id="Reset" value="Reset">\r\n                              <\/div><\/td>\r\n                            <\/tr>\r\n                          <\/table>\r\n                        <\/form>');