// cta-left.js
document.write('<img src="/images/cta-call.png" border=0 usemap="#114401" width=171 height=96>')
document.write('<table width="171" border="0" cellspacing="0" cellpadding="0">')
document.write('<tr>')
document.write('<td colspan=3><img src="/images/cta-box-top-qcontact.png" width=171 height=26 border=0></td>')
document.write('</tr>')
document.write('<tr>')
document.write('<td width="8" background="/images/cta-box-left.png"><img src="/images/spacer.gif" width=8 height=1 border=0></td>')
document.write('<td width="155" background="/images/cta-box-inside.png"><br>')
document.write('<table width="100%" border="0" cellspacing="0" cellpadding="0" class=boxTxt>')
document.write('<form method=post action="/ufmj/mailit.php">')
document.write('<input type="hidden" name="recipient" value="1" />')
document.write('<input type=hidden name="subject" value="Quick Contact Form">')
document.write('<tr>')
document.write('<td class="boxTxt3"><font size="1">Name&nbsp;&nbsp;(required)</font></td>')
document.write('</tr>')
document.write('<tr>')
document.write('<td><input type="Text" name="name" style="width:154px" class=boxTxt1></td>')
document.write('</tr>')
document.write('<tr>')
document.write('<td class="boxTxt3"><font size="1">Phone</font></td>')
document.write('</tr>')
document.write('<tr>')
document.write('<td><input type=text name="Phone" style="width:154px" class=boxTxt1></td>')
document.write('</tr>')
document.write('<tr>')
document.write('<td class="boxTxt3"><font size="1">Email&nbsp;&nbsp;(required)</font></td>')
document.write('</tr>')
document.write('<tr>')
document.write('<td><input type=text name="email" style="width:154px" class=boxTxt1></td>')
document.write('</tr>')
document.write('<tr>')
document.write('<td class="boxTxt3"><font size="1">Area of Interest&nbsp;&nbsp;(required)</font></td>')
document.write('</tr>')
document.write('<tr>')
document.write('<td><select name="send_to" size="1" class=boxTxt1 id="select">')
document.write('<option value="General Interest">General Interest</option><option value="Lasik">Lasik</option><option value="Botox Cosmetic">Botox Cosmetic</option><option value="Cataracts">Cataracts</option><option value="Contact Lenses">Contact Lenses</option><option value="Cornea">Cornea</option><option value="Eyelid Surgery">Eyelid Surgery</option><option value="Glaucoma">Glaucoma</option><option value="Optical Services">Optical Services</option><option value="Pediatric Eye Care">Pediatric Eye Care</option><option value="Retina">Retina</option><option value="Routine Eye Exams">Routine Eye Exams</option><option value="Skin Solutions">Skin Solutions</option>')
document.write('</select></td>')
document.write('</tr>')
document.write('<tr>')
document.write('<td class="boxTxt3"><font size="1">Message</font></td>')
document.write('</tr>')
document.write('<tr>')
document.write('<td><textarea name="comments" style="width:154px" rows="4" class="boxTxt1"></textarea></td>')
document.write('</tr>')
document.write('<tr>')
document.write('<td align=center><br><input type="Image" name="Submit" src="/images/btn-submit.png"></td>')
document.write('</tr></form>')
document.write('</table>')
document.write('</td>')
document.write('<td width="8" background="/images/cta-box-right.png"><img src="images/spacer.gif" width=8 height=1 border=0></td>')
document.write('</tr>')
document.write('<tr>')
document.write('<td colspan=3><img src="/images/cta-box-bottom.png" width=171 height=14 border=0></td>')
document.write('</tr>')
document.write('</table>')

document.write('<a href="survey.html"><img src="/images/cta-survey.png" border=0 width=171 height=96></a>')

document.write('<img src="/images/ill-tops-in-gr.gif" width=171 height=60 border=0>');

document.write('<img src="/images/Top-25-Prac_Solid1c_09.png" width=171 height=164 border=0>');