<!--
document.write("<div id='mictbl'><form action='/contact_dentist/' method='post'  name='fsform' id='fsform' onsubmit='return sf();'><table cellspacing='0' align='right'>"
+"<tr><td>&nbsp;</td><td><h1>Contact Form</h1></td><tr>"
+"<td class='tx'>Name"
+"</td>"
+"<td><input type='text' name='name' id='name' value='"+namevalue+"' />"
+"</td>"
+"</tr>"
+"<tr>"
+"<td class='tx'>E-mail"
+"</td>"
+"<td><input type='text' name='em' id='em' value='"+emvalue+"' />"
+"</td>"
+"</tr>"
+"<tr>"
+"<td class='tx tx1'>Comments"
+"</td>"
+"<td><textarea name='msg'>"+msgvalue+"</textarea>"
+"</td>"
+"</tr>"
+"<tr>"
+"<td>&nbsp;"
+"</td>"
+"<td ><input type='submit' name='submit' id='submit' value='Submit' />"
+"</td>"
+"</tr>"
+"</table><input type='hidden' name='osd' value='' /><input type='text' name='dgt04' value='23434' id='dfr' /></form>");

// -->
