document.write("<center><form method=\"post\" action=\"http://www.aweber.com/scripts/addlead.pl\"><input type=\"hidden\" name=\"meta_web_form_id\" value=\"700586020\"><input type=\"hidden\" name=\"meta_split_id\" value=\"\"><input type=\"hidden\" name=\"unit\" value=\"askdrtan\"><input type=\"hidden\" name=\"redirect\" value=\"http://painrelief.com.sg/thankyou.php\" id=\"redirect_f1fffe958a4268c9a9e41d9be4ae358a\"><input type=\"hidden\" name=\"meta_redirect_onlist\" value=\"\"><input type=\"hidden\" name=\"meta_adtracking\" value=\"\"><input type=\"hidden\" name=\"meta_message\" value=\"1\"><input type=\"hidden\" name=\"meta_required\" value=\"name,from,custom Telephone,custom I Agree2,custom I Agree\"><input type=\"hidden\" name=\"meta_forward_vars\" value=\"0\"><table><tr><td colspan=2><center><div style=\"font-weight: bold; font-size:14px;font-family: arial;\">If you have any queries, please drop us an email.</div><div style=\"font-weight: bold; font-size:14px;font-family: arial;\">Dr Tan will get back to you as soon as possible.&nbsp;</div><div>&nbsp;</div></center></td></tr><tr><td align=\"left\" valign=\"top\">Your Message:</td><td align=\"left\"><textarea name=\"custom Your Message\" rows=\"10\" cols=\"30\"></textarea></td></tr><tr><td align=\"left\">Name:</td><td align=\"left\"><input type=\"text\" name=\"name\" value=\"\" size=\"20\"></td></tr><tr><td align=\"left\">Email Address:</td><td align=\"left\"><input type=\"text\" name=\"from\" value=\"\" size=\"20\"></td></tr><tr><td align=\"left\">Telephone:</td><td align=\"left\"><input type=\"text\" name=\"custom Telephone\" value=\"\" size=\"20\"></td></tr><tr><td colspan=\"2\" align=\"left\"><input type=\"checkbox\" name=\"custom I Agree2\"> I understand that this form is for general questions only and not for emergency advice.</td></tr><tr><td colspan=\"2\" align=\"left\"><input type=\"checkbox\" name=\"custom I Agree\"> I understand that this does not replace a consultation and care by my own doctor</td></tr>    <tr><td colspan=2><center></center></td></tr><tr><td align=\"center\" colspan=\"2\"><input type=\"submit\" name=\"submit\" value=\"Submit\"></td></tr></table></form></center>");

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