document.write("<title>Order Contacts Phoenixville Eye Care Specialists Web Form</title>\n");
document.write("<scr"+"ipt language=javascr"+"ipt>\n");
document.write("function TAMax( ta, countspan, maxlength ) {\n");
document.write(" if (ta.value.length > maxlength){\n");
document.write(" 	ta.value = ta.value.substring( 0, maxlength );\n");
document.write("  	ta.blur();\n");
document.write("  	ta.focus();\n");
document.write("  	return false;\n");
document.write(" 	}\n");
document.write(" else {\n");
document.write("  	countspan.innerHTML = maxlength - ta.value.length;\n");
document.write(" 	}\n");
document.write("}\n");
document.write("</scr"+"ipt>\n");
document.write("<form  method=POST action=\"http://www.phoenixvilleeyecare.com/cgi-bin/csFormbuilder/csFormbuilder.cgi\" name=\"form_7\"  >\n");
document.write("<input type=hidden name=form-id value=\"7\">\n");
document.write("<input type=hidden name=command value=\"mailform\">\n");
document.write("<link rel=\"stylesheet\" type=\"text/css\" href=\"http://www.phoenixvilleeyecare.com/csFormbuilder/forms/ContactPECContactLensOrder.css\">\n");
document.write("<table border=\"0\" cellspacing=\"0\" cellpadding=\"3\">\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">First Name</td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"FirstName\"  size=\"35\"   maxlength=\"50\" ></td>\n");
document.write("</tr>\n");
document.write("</table> <!-- tr ph 0--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">Last Name</td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"LastName\"  size=\"35\"   maxlength=\"50\" ></td>\n");
document.write("</tr>\n");
document.write("</table> <!-- tr ph 1--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">Address 1</td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"Address1\"  size=\"35\"   maxlength=\"75\" ></td>\n");
document.write("</tr>\n");
document.write("</table> <!-- tr ph 2--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">Address 2</td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"Address2\"  size=\"35\"   maxlength=\"75\" ></td>\n");
document.write("</tr>\n");
document.write("</table> <!-- tr ph 3--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">City</td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"City\"  size=\"35\"   maxlength=\"75\" ></td>\n");
document.write("</tr>\n");
document.write("</table> <!-- tr ph 4--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">State </td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><select name=\"State\"  size=\"1\"   onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\">\n");
document.write("<option value=\"\"></option>\n");
document.write("<option value=\"AK\">AK-Alaska</option>\n");
document.write("<option value=\"AL\">AL-Alabama</option>\n");
document.write("<option value=\"AR\">AR-Arkansas</option>\n");
document.write("<option value=\"AZ\">AZ-Arizona</option>\n");
document.write("<option value=\"CA\">CA-California</option>\n");
document.write("<option value=\"CO\">CO-Colorado</option>\n");
document.write("<option value=\"CT\">CT-Connecticut</option>\n");
document.write("<option value=\"DC\">DC-District of Columbia</option>\n");
document.write("<option value=\"DE\">DE-Delaware</option>\n");
document.write("<option value=\"FL\">FL-Florida</option>\n");
document.write("<option value=\"GA\">GA-Georgia</option>\n");
document.write("<option value=\"HI\">HI-Hawaii</option>\n");
document.write("<option value=\"IA\">IA-Iowa</option>\n");
document.write("<option value=\"ID\">ID-Idaho</option>\n");
document.write("<option value=\"IL\">IL-Illinois</option>\n");
document.write("<option value=\"IN\">IN-Indiana</option>\n");
document.write("<option value=\"KS\">KS-Kansas</option>\n");
document.write("<option value=\"KY\">KY-Kentucky</option>\n");
document.write("<option value=\"LA\">LA-Louisiana</option>\n");
document.write("<option value=\"MA\">MA-Massachusetts</option>\n");
document.write("<option value=\"MD\">MD-Maryland</option>\n");
document.write("<option value=\"ME\">ME-Maine</option>\n");
document.write("<option value=\"MI\">MI-Michigan</option>\n");
document.write("<option value=\"MN\">MN-Minnesota</option>\n");
document.write("<option value=\"MO\">MO-Missouri</option>\n");
document.write("<option value=\"MS\">MS-Mississippi</option>\n");
document.write("<option value=\"MT\">MT-Montana</option>\n");
document.write("<option value=\"NC\">NC-North Carolina</option>\n");
document.write("<option value=\"ND\">ND-North Dakota</option>\n");
document.write("<option value=\"NE\">NE-Nebraska</option>\n");
document.write("<option value=\"NH\">NH-New Hampshire</option>\n");
document.write("<option value=\"NJ\">NJ-New Jersey</option>\n");
document.write("<option value=\"NM\">NM-New Mexico</option>\n");
document.write("<option value=\"NV\">NV-Nevada</option>\n");
document.write("<option value=\"NY\">NY-New York</option>\n");
document.write("<option value=\"OH\">OH-Ohio</option>\n");
document.write("<option value=\"OK\">OK-Oklahoma</option>\n");
document.write("<option value=\"OR\">OR-Oregon</option>\n");
document.write("<option value=\"OT\">OT-Other</option>\n");
document.write("<option value=\"PA\">PA-Pennsylvania</option>\n");
document.write("<option value=\"RI\">RI-Rhode Island</option>\n");
document.write("<option value=\"SC\">SC-South Carolina</option>\n");
document.write("<option value=\"SD\">SD-South Dakota</option>\n");
document.write("<option value=\"TN\">TN-Tennessee</option>\n");
document.write("<option value=\"TX\">TX-Texas</option>\n");
document.write("<option value=\"UT\">UT-Utah</option>\n");
document.write("<option value=\"VA\">VA-Virginia</option>\n");
document.write("<option value=\"VT\">VT-Vermont</option>\n");
document.write("<option value=\"WA\">WA-Washington</option>\n");
document.write("<option value=\"WI\">WI-Wisconsin</option>\n");
document.write("<option value=\"WV\">WV-West Virginia</option>\n");
document.write("<option value=\"WY\">WY-Wyoming</option>\n");
document.write("</select>&nbsp;</td>\n");
document.write("</tr>\n");
document.write("</table>   <table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">Zip Code</td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"ZipCode\"  size=\"9\"   maxlength=\"25\" ></td>\n");
document.write("</tr>\n");
document.write("</table><!-- tr ph 6--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">Email Address</td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"Email\"  size=\"35\"   maxlength=\"100\" ></td>\n");
document.write("</tr>\n");
document.write("</table> <!-- tr ph 7--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">Home Phone</td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"HomePhone\"  size=\"25\"   maxlength=\"30\" ></td>\n");
document.write("</tr>\n");
document.write("</table> <!-- tr ph 8--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">Work Phone</td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"WorkPhone\"  size=\"25\"   maxlength=\"30\" ></td>\n");
document.write("</tr>\n");
document.write("</table> <!-- tr ph 9--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">Cell Phone</td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"CellPhone\"  size=\"25\"   maxlength=\"30\" ></td>\n");
document.write("</tr>\n");
document.write("</table> <!-- tr ph 10--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">Birth year</td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"Birthyear\"  size=\"15\"   maxlength=\"20\" ></td>\n");
document.write("</tr>\n");
document.write("</table> <!-- tr ph 11--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\"  valign=\"top\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">Which eye </td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><table border=0 cellspacing=2 cellpadding=0><tr><td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=checkbox name=\"WhichEye\" value=\"Right\"></td><td class=\"textLabel\">Right</td>\n");
document.write("<td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=checkbox name=\"WhichEye\" value=\"Left\"></td><td class=\"textLabel\">Left</td>\n");
document.write("<td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=checkbox name=\"WhichEye\" value=\"Both\"></td><td class=\"textLabel\">Both</td>\n");
document.write("</tr></table>\n");
document.write("</td>\n");
document.write("</tr>\n");
document.write("</table> <!-- tr ph 12--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"right\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"right\"># Boxes per eye: (if disposable)</td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"NumberBoxes\"  size=\"15\"   maxlength=\"25\" ></td>\n");
document.write("</tr>\n");
document.write("</table> <!-- tr ph 13--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">Submit to vision insurance (if eligible)</td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"Visioninsurance\"  size=\"35\"   maxlength=\"55\" ></td>\n");
document.write("</tr>\n");
document.write("</table> <!-- tr ph 14--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">Comments</td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><textarea  onfocus=\"className='textFieldFocus'\" name=\"Comments\"  rows=\"5\" cols=\"35\"   maxlength=\"1000\"  ONCHANGE=\"TAMax(this,document.getElementById('Comments_D'),1000);\" ONBLUR=\"TAMax(this,document.getElementById('Comments_D'),1000);className='textField';\" ONKEYUP=\"TAMax(this,document.getElementById('Comments_D'),1000);\"></textarea><br><span id=\"Comments_D\">1000</span>&nbsp;characters remaining.</td>\n");
document.write("</tr>\n");
document.write("</table> <!-- tr ph 15--></td></tr>\n");
document.write("<tr><td class=\"textLabel\" colspan=2  height=\"5\" ></td></tr><tr><td nowrap class=\"textLabel\" align=\"left\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\">Verify Authentication Code:</td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><img id=\"Verification_img\" align=absmiddle border=0 width=59 height=15 src=\"\"><input type=hidden id=\"Verification_sid\" name=\"Verification_sid\" value=\"\"> <scr"+"ipt language=javascr"+"ipt src=\"http://www.phoenixvilleeyecare.com/cgi-bin/csFormbuilder/vimage.cgi?command=g&f=Verification\"></scr"+"ipt>&nbsp;<input  onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"Verification\"  ></td>\n");
document.write("</tr>\n");
document.write("</table> <!-- tr ph 16--></td></tr>\n");
document.write("<tr><td colspan=2 align=\"left\"><input onmouseover=\"className='buttonfieldFocus'\" onmouseout=\"className='buttonfield'\" class=\"buttonfield\" type=submit value=\":: Submit ::\"></td></tr>\n");
document.write("</table>\n");
document.write("</form>\n");