<?xml version="1.0" encoding="UTF-8"?>

<form url="file_upload_form.php"
 window="_self"
 method="POST"
 fontname="MS Sans Serif"
 width="505"
 height="405"
 bkcolor="0xC8D7DB"
 transparent="f"
 fontcolor="0x000000"
 outlinecolor="0x333300"
 themecolor="0xFFFF99"
 fontcolor2="#000000"
 bkcolor2="#FFFFFF"
 includeresults="false"
 emailuser="false"
 verifymessage="The E-Mail address you entered does not match !"
 reqmessage="One or More Fields are Required"
 transition="0"
 autoresponseincluderesults="t"
 autoresponseaddtotop="t"
 usephp="true"
 disableclicktoactiveprompt="true"
 extensions="*.pdf;*.swf"
>

<hidden
 name="subject"
 value="New Patient Questionnaire"
></hidden>

<image
 image="email-1.jpg"
 x="428"
 y="12"
></image>

<textinput
 name="Name"
 x="8"
 y="64"
 w="143"
 h="22"
 initvalue=""
 bkcolor="0xFFFFFF"
  fontname="Arial"
  fontcolor="0x000000"
 editable="true"
>
</textinput>

<textinput
 name="E-Mail Address"
 x="176"
 y="64"
 w="175"
 h="22"
 initvalue=""
 bkcolor="0xFFFFFF"
  fontname="Arial"
  fontcolor="0x000000"
 emailbox="true"
 editable="true"
>
</textinput>

<textinput
 name="City"
 x="8"
 y="120"
 w="99"
 h="22"
 initvalue=""
 bkcolor="0xFFFFFF"
  fontname="Arial"
  fontcolor="0x000000"
 editable="true"
>
</textinput>

<combobox
 name="State"
 x="120"
 y="120"
 bkcolor="0xFFFFFF"
 fontcolor="0x000000"
 isemail="false"
 w="100"
 h="20">
  <item name="Alabama"></item>
  <item name="Alaska"></item>
  <item name="Arizona"></item>
  <item name="Arkansas"></item>
  <item name="California"></item>
  <item name="Colorado"></item>
  <item name="Connecticut"></item>
  <item name="Delaware"></item>
  <item name="District of Columbia"></item>
  <item name="Florida"></item>
  <item name="Georgia"></item>
  <item name="Hawaii"></item>
  <item name="Idaho"></item>
  <item name="Illinois"></item>
  <item name="Indiana"></item>
  <item name="Iowa"></item>
  <item name="Kansas"></item>
  <item name="Kentucky"></item>
  <item name="Louisiana"></item>
  <item name="Maine"></item>
  <item name="Maryland"></item>
  <item name="Massachusetts"></item>
  <item name="Michigan"></item>
  <item name="Minnesota"></item>
  <item name="Mississippi"></item>
  <item name="Missouri"></item>
  <item name="Montana"></item>
  <item name="Nebraska"></item>
  <item name="Nevada"></item>
  <item name="New Hampshire"></item>
  <item name="New Jersey"></item>
  <item name="New Mexico"></item>
  <item name="New York"></item>
  <item name="North Carolina"></item>
  <item name="North Dakota"></item>
  <item name="Ohio"></item>
  <item name="Oklahoma"></item>
  <item name="Oregon"></item>
  <item name="Pennsylvania"></item>
  <item name="Rhode Island"></item>
  <item name="South Carolina"></item>
  <item name="South Dakota"></item>
  <item name="Tennessee"></item>
  <item name="Texas"></item>
  <item name="Utah"></item>
  <item name="Vermont"></item>
  <item name="Virginia"></item>
  <item name="Washington"></item>
  <item name="West Virginia"></item>
  <item name="Wisconsin"></item>
  <item name="Wyoming"></item>
</combobox>

<textinput
 name="Zip Code"
 x="232"
 y="120"
 w="63"
 h="22"
 initvalue=""
 bkcolor="0xFFFFFF"
  fontname="Arial"
  fontcolor="0x000000"
 editable="true"
>
</textinput>

<textinput
 name="Phone Number"
 x="312"
 y="120"
 w="175"
 h="22"
 initvalue=""
 bkcolor="0xFFFFFF"
  fontname="Arial"
  fontcolor="0x000000"
 editable="true"
>
</textinput>

<textarea
 name="My Comments"
 x="9"
 y="249"
 w="291"
 h="104"
 initvalue=""
 wordwrap="true"
 editable="true"
 bkcolor="0xFFFFFF"
  fontsize="12"
  fontname="Arial"
  fontcolor="0x000000"
></textarea>

<submitbutton
 name="submitbutton1"
 x="345"
 y="363"
 w="90"
 h="29"
 label="Send"
 fontname="Arial"
 fontcolor="0x000000"
 image="submitrectanglesmall.png"
  fontsize="12"
></submitbutton>

<browsebutton
 name="Submit Button 1"
 x="156"
 y="180"
 w="84"
 h="23"
 label="Locate"
 fontname="Arial"
 fontcolor="0x000000"
  fontsize="12"
></browsebutton>

<label
 name="My Text 1"
 x="8"
 y="8"
 w="322"
 h="22"
 text="Upload your Patient Questionnaire"
 fontbold="bold"
  fontname="Arial"
  fontcolor="0x333300"
  fontsize="19"
></label>

<label
 name="My Text 2"
 x="8"
 y="48"
 w="41"
 h="16"
 text="Name"
 fontbold="bold"
  fontname="Arial"
  fontcolor="0x333300"
  fontsize="13"
></label>

<label
 name="My Text 3"
 x="8"
 y="101"
 w="28"
 h="16"
 text="City"
 fontbold="bold"
  fontname="Arial"
  fontcolor="0x333300"
  fontsize="13"
></label>

<label
 name="My Text 4"
 x="120"
 y="101"
 w="37"
 h="16"
 text="State"
 fontbold="bold"
  fontname="Arial"
  fontcolor="0x333300"
  fontsize="13"
></label>

<label
 name="My Text 5"
 x="232"
 y="100"
 w="60"
 h="16"
 text="Zip Code"
 fontbold="bold"
  fontname="Arial"
  fontcolor="0x333300"
  fontsize="13"
></label>

<label
 name="My Text 7"
 x="176"
 y="48"
 w="97"
 h="16"
 text="E-Mail Address"
 fontbold="bold"
  fontname="Arial"
  fontcolor="0x333300"
  fontsize="13"
></label>

<label
 name="My Text 8"
 x="312"
 y="101"
 w="99"
 h="16"
 text="Phone Number"
 fontbold="bold"
  fontname="Arial"
  fontcolor="0x333300"
  fontsize="13"
></label>

<label
 name="My Text 9"
 x="8"
 y="185"
 w="141"
 h="16"
 text="Select File To Upload"
 fontbold="bold"
  fontname="Arial"
  fontcolor="0x003300"
  fontsize="13"
></label>

<label
 name="My Text 10"
 x="8"
 y="232"
 w="164"
 h="16"
 text="Instructions or Comments"
 fontbold="bold"
  fontname="Arial"
  fontcolor="0x333300"
  fontsize="13"
></label>

<captcha
 name="My Captcha 1"
 x="324"
 y="253"
 w="133"
 h="100"
 text="Enter Key Here:"
 fnt="Arial"
 fntclr="0x000000"
 fntsize="11"
 bkbdrcolor="0x000000"
 bkfillclr="0xFFFFFF"
 bkdobdr="t"
 bkbdrsolid="t"
 bkdobk="t"
 bkfillalpha="100"
 message="Incorrect key!"
></captcha>

</form>