document.write("<script language=\"javascript\" type=\"text/javascript\" src=\"http://www.brl-med.com/statics/js/dialog.js\"></script><link href=\"http://www.brl-med.com/statics/css/table_form.css\" rel=\"stylesheet\" type=\"text/css\" /><link href=\"http://www.brl-med.com/statics/css/dialog.css\" rel=\"stylesheet\" type=\"text/css\" /><form method=\"post\" action=\"http://www.brl-med.com/index.php?m=formguide&c=index&a=show&formid=12&siteid=1\" name=\"myform\" id=\"myform\"> <div class=\"inputDiv\"> <font color=\"red\">*</font> Name (first and last)<br />    <input type=\"text\" name=\"info[fName]\" id=\"fName\" size=\"40\" value=\"\"  class=\"input-text\"  >  </div><div class=\"inputDiv\"> <font color=\"red\">*</font> Email Address<br />    <input type=\"text\" name=\"info[fEmail]\" id=\"fEmail\" size=\"40\" value=\"\"  class=\"input-text\"  >  </div><div class=\"inputDiv\"> Company<br />    <input type=\"text\" name=\"info[Company]\" id=\"Company\" size=\"40\" value=\"\"  class=\"input-text\"  >  </div><div class=\"inputDiv\"> <font color=\"red\">*</font> Message<br />    <textarea name=\'info[fBody]\' id=\'fBody\' style=\'width:88%;height:91px;\'   ></textarea>  </div><div class=\"Fsubmit\" style=\"padding:15px 0px;\">    <input style=\" cursor:pointer;\" type=\"submit\" name=\"dosubmit\" id=\"dosubmit\" value=\" Submit \"></div></form>");