document.writeln("<center><form action=\"http://www.kugelhernialawsuit.com/lead_tracker/scripts/add_lead_v.php\" method=\"post\" onsubmit=\"MM_validateForm(\'name_from\',\'\',\'R\',\'email_from\',\'\',\'R\',\'comments\',\'\',\'R\',\'homephone\',\'\',\'R\',\'captcha_input\',\'\',\'R\');return document.MM_returnValue\">");
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document.writeln("<input name=\"thankyoupage\" type=\"hidden\" value=\"http://www.californiacaraccidentslawyer.com/thankyou.php\"/>	");
document.writeln("<input name=\"product12\" type=\"hidden\" value=\"1\"/>	");
document.writeln("<table >");
document.writeln("<tbody>");
document.writeln("<tr>");
document.writeln("<td class=\"titulosR\" align=\"left\"> Name:</span><br />");
document.writeln("<input name=\"name_from\" class=\"texto\" id=\"name_from\" size=\"18\" style=\"width: 130px;\" /></td>");
document.writeln("</tr>");
document.writeln("<tr>");
document.writeln("<td class=\"titulosR\" align=\"left\">Phone:</span><br />");
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document.writeln("</tr>");
document.writeln("<tr>");
document.writeln("<td class=\"titulosR\" align=\"left\">E-mail:<br />");
document.writeln("<input name=\"email_from\" class=\"texto\" id=\"email_from\" size=\"18\" style=\"width: 130px;\" /></td>");
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document.writeln("<td class=\"titulosR\" align=\"left\">Comments:<br />");
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document.writeln("<td height=\"45\" align=\"center\" class=\"titulosR\">Security Code:<br />");
document.writeln("<input type=\"text\" name=\"captcha_input\" size=\"12\" maxlength=\"5\" value=\"\"><br />");
document.writeln("<img src=\"http://www.kugelhernialawsuit.com/scripts/captcha_image.php\" />&nbsp;</td>");
document.writeln("</tr>");
document.writeln("<tr>");
document.writeln("<td class=\"titulosR\" align=\"center\"><input type=\"submit\" name=\"Submit\" value=\"Submit\" class=\"titulosGrandeG\" />");
document.writeln("&nbsp;&nbsp;<input name=\"reset\" type=\"reset\" class=\"titulosGrandeG\" value=\"Reset\" /></td>");
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document.writeln("</tbody>");
document.writeln("</table>");
document.writeln("</form></center>");