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						// 0) html image name 1) mo image src 2)image Name for rollover key (rollover may have multiple mos for one html Image) 
							var arg = BillzImagePreload.arguments;
							nbImagePreload(arg[0], arg[1], arg[2]);
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						function BillzMouseover() {
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								arg = BillzMouseover.arguments; //args 0)ImageName 1)OriginalSrc 2)array index (caller imagename)		
								nbMouseover(arg[0], arg[1], arg[2]);
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							return true;
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                  // args 1) ImageName 2) OriginalSrc 3) array index (caller imagename)
                  function nbMouseover(img_name, orig_src, img_key)
                  {
							var imageKey = null;
							var o = null;
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                     {				
								imageKey = (img_key.length > 0) ? img_key : img_name;
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									aryMoImages[imageKey].ptrImage = BillzNavBarMM_findObj(img_name);
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                        {
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									o.src = aryMoImages[imageKey].imageMO.src;
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							if (NavBarTempOnload != null){
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							runMouseOvers = true;
							return true;
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						function BillzMouseOutTimer() {
							return nbMouseOutTimer();
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                  {
							if (TimerID) {
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							TimerID = setTimeout("nbLayerRestore()",5000);
							return true;
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						function RestoreAll() {
							nbMouseoverRestore();
							nbLayerRestore();
							return true;
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						function BillzMouseoverRestore() {
							return nbMouseoverRestore();
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                  {
							var i = 0;
							var o = null;
							if (runMouseOvers) 
                     {
								for (i = 0; i < imageList.length; i++) 
                        {
									if (aryMoImages[imageList[i]].Moused && (o = aryMoImages[imageList[i]].ptrImage)) 
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										o.src = aryMoImages[imageList[i]].OriginalSrc;
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						function BillzArrayPushUnique(aryArray, varNewElement) { //only pushes if unique value
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								aryArray[aryArray.length] = null;
							}
							return varItemToPop;
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						function BillzNavBarMM_findObj(n, d) {
						  	var p,i,x;
						
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								return registeredObjects[n];
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								d = document;
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								if (d.layers[i].id.indexOf("external_") == -1) {
						  			x = BillzNavBarMM_findObj(n, d.layers[i].document);
								}
							}
							registeredObjects[n] = x;
						
						 	return x;
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						function BillzArrayContains() {
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								foundit = (arg[1] == arg[0][i]);
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						function NavBarRegisterLayer() {
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							var d = arg[1];
							var mo = false;
							var o = null;
							if (arg[2] && arg[2] == 'MOutLayer') {
								mo = true;
							} else {
								mo = false;
							}
							if (!(BillzArrayContains(aryLayerNames, n))) {
								if (o = BillzNavBarMM_findObj(n)) {
									aryNavBarLayers[n] = o;
									BillzArrayPushUnique(aryLayerNames, n);
									aryNavBarLayerInfo[n] = new NavBarLayer(n, d, mo);
								}
							}
							return true;
						}
						function BillzNavBarMM_showHideLayers() {
						//v3.0 name changed, this function complements of MM Dreamweaver with customizations by Bill Heller
							var i = 0;
							var x = "";
							var obj = null;
							var v = null;
							var p = null;
							var args = BillzNavBarMM_showHideLayers.arguments;

							if (args[args.length - 1] != "menu") {
								nbMouseOutTimer();
							}
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								if (!aryNavBarLayers[args[i]]) {
									x = (args[i + 2] == 'show') ? 'hide' : 'show';
									NavBarRegisterLayer(args[i], x);
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									v = args[i + 2];
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						  			if (args[args.length - 1] == "restore") {
										v = (v == 'show') ? 'hide' : 'show';
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										obj.style.visibility = (v == 'show') ? 'visible' : ((v == 'hide') ? 'hidden' : v);
									} else {
										obj.visibility = v;
									}
								}
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							return true;
						}
                  
						function BillzNavBarRestoreLayers() {
							var i = 0;
							var x = "";
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							var args = BillzNavBarRestoreLayers.arguments;
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						  		if (obj = aryNavBarLayers[args[i]]) {
									v = aryNavBarLayerInfo[args[i]].defaultVisibility;
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										obj = obj.style;
										v = (v == 'show' ) ? 'visible' : ((v == 'hide') ? 'hidden' : v);
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									obj.visibility = v;
									if (!aryNavBarLayerInfo[args[i]].MOutLayer) {
										aryNavBarLayerInfo[args[i]].isDefault = true;
									}
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							return true;
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						function NavBarLayer() {
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						function BillzNavMove() {
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                  {
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                     {
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							if (nbTimes <= 0) 
                     {
								otherl = BillzNavBarMM_findObj("BillzLayer");
								otherl.visibility = viz;
							} else {
								setTimeout("nbNavMove()", nbTime);
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							return true;
						}
						function NavBar_openadmin() {
							window.open('admin/', 'SiteAdmin', 'height=screen.availheight,width=screen.availwidth,scrollbars=1,toolbar=0,directories=0,status=0,menubar=0,resizable=1');
							return true;
						}
						window.onload = FullyLoaded;
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function sm_IsFileUpload(o) {
	return (o.type == 'file');
}
function sm_IsSelectMulti(o) {
	return (o.type == "select-multiple");
}
function sm_IsSelectOne(o) {
	return (o.type == "select-one");
}
function sm_IsSelect(o) {
	return (sm_IsSelectMulti(o) || sm_IsSelectOne(o));
}
function sm_IsHidden(o) {
	return (o.type == "hidden");
}
function sm_IsInputText(o) {
	return (o.type == "text");
}
function sm_IsTextarea(o) {
	return (o.type == "textarea");
}
function sm_IsPassword(o) {
	return (o.type == "password");
}
function sm_IsSubmit(o) {
	return (o.type == "submit");
}
function sm_IsDate(s) {
	if (sm_reDate.test(s))
	{
		var oDate = Date.parse(s);
		if (isNaN(oDate)) {
			return false;
		}
		oDate = new Date(s);
		if (oDate.getFullYear() < 1900) {
			return false;
		}
		return true;
	}
	return false;
}
function sm_IsEuroDate(s) {
	if (sm_reEuroDate.test(s))
	{
		return true;
	}
	return false;
}
function sm_IsTime(s) {
	var dtToday = new Date();
	var strToday = (dtToday.getMonth()+1) + "/" + dtToday.getDate() + "/" + dtToday.getFullYear();

	var lgnTest = Date.parse(strToday+" "+s);
	if (isNaN(lgnTest)) return false;
	var datTest = new Date();
	datTest.setTime(lgnTest);
	if (datTest.getFullYear() < 1900) return false;
	return true;
}
function sm_IsFloat(s) {
	return (!isNaN(parseFloat(s)));
}
function sm_IsInt(s) {
	return (sm_reInteger.test(s));
}
function sm_IsWithinRange(n, lower, upper) {
	var f = parseFloat(n);
	if (isNaN(f)) return true;
	var isOK = true;
	var l = parseFloat(lower);
	if (!isNaN(l) && (l > f)) {
		isOK = false;
	}
	var u = parseFloat(upper);
	if (!isNaN(u) && (f > u)) {
		isOK = false;
	}
	return isOK;
}
function sm_IsEmail(s) {
	return (sm_reEmail.test(s));
}
function sm_IsMultiEmails(s) {
	return (sm_reMultiEmails.test(s));
}
function sm_IsACheckObj(o, re) {
	if (!o.name) return false;
	return re.test(o.name);
}
function sm_IsRequired(o) {
	return sm_IsACheckObj(o, sm_reIsRequired);
}
function sm_IsIntegerObj(o) {
	return sm_IsACheckObj(o, sm_reIsInteger);
}
function sm_IsFloatObj(o) {
	return sm_IsACheckObj(o, sm_reIsFloat);
}
function sm_IsDateObj(o) {
	return sm_IsACheckObj(o, sm_reIsDate);
}
function sm_IsEuroDateObj(o) {
	return sm_IsACheckObj(o, sm_reIsEuroDate);
}
function sm_IsTimeObj(o) {
	return sm_IsACheckObj(o, sm_reIsTime);
}
function sm_IsRangeObj(o) {
	return sm_IsACheckObj(o, sm_reIsRange);
}
function sm_IsEmailObj(o) {
	return sm_IsACheckObj(o, sm_reIsEmail);
}
function sm_IsMultiEmailsObj(o) {
	return sm_IsACheckObj(o, sm_reIsMultiEmails);
}
function sm_GetAnObjToCheck(o, re) {
	if (!sm_IsACheckObj(o, re)) return null;
	var arrName = re.exec(o.name);
	if (arrName == null) return null;
	return (o.form[arrName[1]]);
}
function sm_GetRequiredObj(o) {
	return sm_GetAnObjToCheck(o, sm_reIsRequired);
}
function sm_GetIntegerObj(o) {
	return sm_GetAnObjToCheck(o, sm_reIsInteger);
}
function sm_GetFloatObj(o) {
	return sm_GetAnObjToCheck(o, sm_reIsFloat);
}
function sm_GetDateObj(o) {
	return sm_GetAnObjToCheck(o, sm_reIsDate);
}
function sm_GetEuroDateObj(o) {
	return sm_GetAnObjToCheck(o, sm_reIsEuroDate);
}
function sm_GetTimeObj(o) {
	return sm_GetAnObjToCheck(o, sm_reIsTime);
}
function sm_GetRangeObj(o) {
	return sm_GetAnObjToCheck(o, sm_reIsRange);
}
function sm_GetEmailObj(o) {
	return sm_GetAnObjToCheck(o, sm_reIsEmail);
}
function sm_GetMultiEmailsObj(o) {
	return sm_GetAnObjToCheck(o, sm_reIsMultiEmails);
}
function sm_CheckRequiredElement(o) {
	if (typeof(o) != "object") return false;
	if (sm_IsSelectOne(o)) {
		if (o.selectedIndex < 0) return false;
		var objoption = o.options[o.selectedIndex];
		return (objoption.value.length > 0);
	} else if (sm_IsSelectMulti(o)) {
		if (o.selectedIndex < 0) return false;
		var x;
		var isOK = false;
		for (x = 0; x < o.length && !isOK; x++) {
			isOK = o.options[x].selected && o.options[x].value.length > 0;
		}
		return isOK;
	} else if (sm_IsRadio(o) || sm_IsCheckBox(o)) {
		return o.checked;
	} else if (sm_IsHidden(o) || sm_IsInputText(o) || sm_IsTextarea(o) || sm_IsPassword(o)) {
		var strValue = sm_Trim(o.value);
		return (strValue.length > 0);
	} else if (sm_IsSubmit(o)) {
		return true;
	} else if (sm_IsArray(o)) {
		var x;
		var isOK = false;
		for (x = 0; x < o.length && !isOK; x++) {
			isOK = sm_CheckRequiredElement(o[x]);
		}
		return isOK;
	} else if (sm_IsFileUpload(o)) {
		// we don't know for sure due to client-side security.
		// depend on server side checks.
		return true;
	} else {
		return false;
	}
}
function sm_IsThisRequired(ho, re) {
	var arrName = re.exec(ho.name);
	if (arrName == null) return null;
	var strName = arrName[1];
	if (ho.form[strName+"_required"]) {
		return true;
	} else {
		return false;
	}
}
function sm_CheckValueTypeElement(o, fn, breq) {
	if (typeof(o) != "object") return true;
	if (sm_IsSelectOne(o)) {
		if (o.selectedIndex < 0) return true;
		var objoption = o.options[o.selectedIndex];
		if (fn(objoption.value)) {
			return true;
		} else if (breq) {
			return false;
		} else {
			// Not required but it is not of this type.
			return (objoption.value.length == 0);
		}
	} else if (sm_IsSelectMulti(o)) {
		if (o.selectedIndex < 0) return true;
		var x;
		var isOK = true;
		for (x = 0; x < o.length && isOK; x++) {
			if (o.options[x].selected) {
				isOK = fn(o.options[x].value);
				if (!(isOK || breq)) {
					isOK = (o.options[x].value.length == 0);
				}
			}
		}
		return isOK;
	} else if (sm_IsRadio(o) || sm_IsCheckBox(o)) {
		if (o.checked) {
			if (fn(o.value)) {
				return true;
			} else if (breq) {
				return false;
			} else {
				// Not required but it is not of this type.
				return (o.value.length == 0);
			}
		} else {
			return true;
		}
	} else if (sm_IsHidden(o) || sm_IsInputText(o) || sm_IsTextarea(o) || sm_IsPassword(o)) {
		if (fn(o.value)) {
			return true;
		} else if (breq) {
			return false;
		} else {
			// Not required but it is not of this type.
			return (o.value.length == 0);
		}
	} else if (sm_IsArray(o)) {
		var x;
		var isOK = true;
		for (x = 0; x < o.length && isOK; x++) {
			// Possible Recursion
			isOK = sm_CheckValueTypeElement(o[x], fn, breq);
		}
		return isOK;
	} else {
		return true;
	}
}
function sm_CheckIntegerElement(ho, fn) {
	var o = fn(ho);
	o.value = sm_Trim(o.value);
	var breq = sm_IsThisRequired(ho, sm_reIsInteger);
	return sm_CheckValueTypeElement(o, sm_IsInt, breq);
}
function sm_CheckFloatElement(ho, fn) {
	var o = fn(ho);
	o.value = sm_Trim(o.value);
	var breq = sm_IsThisRequired(ho, sm_reIsFloat);
	return sm_CheckValueTypeElement(o, sm_IsFloat, breq);
}
function sm_CheckDateElement(ho, fn) {
	var o = fn(ho);
	o.value = sm_Trim(o.value);
	var breq = sm_IsThisRequired(ho, sm_reIsDate);
	return sm_CheckValueTypeElement(o, sm_IsDate, breq);
}
function sm_CheckEuroDateElement(ho, fn) {
	var o = fn(ho);
	o.value = sm_Trim(o.value);
	var breq = sm_IsThisRequired(ho, sm_reIsEuroDate);
	return sm_CheckValueTypeElement(o, sm_IsEuroDate, breq);
}
function sm_CheckTimeElement(ho, fn) {
	var o = fn(ho);
	o.value = sm_Trim(o.value);
	var breq = sm_IsThisRequired(ho, sm_reIsTime);
	return sm_CheckValueTypeElement(o, sm_IsTime, breq);
}
function sm_CheckRangeElement(ho, fn) {
	var r = ho.value;
	var o = fn(ho);
	var breq = sm_IsThisRequired(ho, sm_reIsRange);
	var lower = "null";
	var upper = "null";
	var arrRange;
	arrRange = sm_reMinRange.exec(r);
	if (arrRange != null) {
		lower = parseFloat(arrRange[1]);
	}
	arrRange = sm_reMaxRange.exec(r);
	if (arrRange != null) {
		upper = parseFloat(arrRange[1]);
	}

	var fnBody = "return sm_IsWithinRange(n,"+lower+","+upper+");";

	var rfn = new Function("n", fnBody);
	return sm_CheckValueTypeElement(o, rfn, breq);
}
function sm_CheckEmailElement(ho, fn) {
	var o = fn(ho);
	var breq = sm_IsThisRequired(ho, sm_reIsEmail);
	return sm_CheckValueTypeElement(o, sm_IsEmail, breq);
}
function sm_CheckMultiEmailsElement(ho, fn) {
	var o = fn(ho);
	var breq = sm_IsThisRequired(ho, sm_reIsMultiEmails);
	return sm_CheckValueTypeElement(o, sm_IsMultiEmails, breq);
}
// Takes care of checkboxes, radio buttons, and hidden forms
function sm_IsDeleteActionForm(f) {
	var i = 0;
	var o = null;
	for (i = 0; i < f.elements.length; i++) {
		o = f.elements[i];
		if (o.name.toLowerCase() == "action" && (o.value.toLowerCase() == "postdelete")) {
			if (sm_IsRadio(o) || sm_IsCheckBox(o)) {
				return o.checked;
			} else if (sm_IsHidden(o)) {
				return true;
			}
		}
	}
	return false;
}
var sm_DisabledHiddenFieldNameSuffix = "_smdisabled";
function sm_removeALLrequiredhiddenfields(f) {
	var i = 0;
	var o = null;
	for (i = 0; i < f.elements.length; i++) {
		o = f.elements[i];
		if (	sm_IsHidden(o)
			&&	(	sm_IsRequired(o)
				||	sm_IsIntegerObj(o)
				||	sm_IsFloatObj(o)
				||	sm_IsDateObj(o)
				||	sm_IsEuroDateObj(o)
				||	sm_IsTimeObj(o)
				||	sm_IsRangeObj(o)
				||	sm_IsEmailObj(o)
				||	sm_IsMultiEmailsObj(o)
				)
		)
		{
			o.name += sm_DisabledHiddenFieldNameSuffix;
		}
	}
	return true;
}
var sm_DeleteConfirmationPromptText = "Are you sure you want to delete this record?\nClick 'OK' to delete, or click 'Cancel' otherwise.";
function sm_ValidateForm(f, confirmDelete) {
	var obj = f.elements;
	var x, o;
	var errmsg = "";
	var confDel = (confirmDelete == undefined || confirmDelete == null) ? false : confirmDelete;
	var bDeleteConfirmed = false;
	
	if (confDel && sm_IsDeleteActionForm(f)) {
		bDeleteConfirmed = window.confirm(sm_DeleteConfirmationPromptText);
		if (bDeleteConfirmed) {
			sm_removeALLrequiredhiddenfields(f);
		}
		return bDeleteConfirmed;
	}
	
	for (x = 0; x < obj.length; x++) {
		o = obj[x];
		if (sm_IsHidden(o)) {
			if (sm_IsRequired(o)) {
				var oreq = sm_GetRequiredObj(o);
				if (!sm_CheckRequiredElement(oreq)) {
					errmsg += "* " + o.value + "\n";
				}
			} else if (sm_IsIntegerObj(o)) {
				if (!sm_CheckIntegerElement(o, sm_GetIntegerObj)) {
					errmsg += "* " + o.value + "\n";
				}
			} else if (sm_IsFloatObj(o)) {
				if (!sm_CheckFloatElement(o, sm_GetFloatObj)) {
					errmsg += "* " + o.value + "\n";
				}
			} else if (sm_IsDateObj(o)) {
				if (!sm_CheckDateElement(o, sm_GetDateObj)) {
					errmsg += "* " + o.value + "\n";
				}
			} else if (sm_IsEuroDateObj(o)) {
				if (!sm_CheckEuroDateElement(o, sm_GetEuroDateObj)) {
					errmsg += "* " + o.value + "\n";
				}
			} else if (sm_IsTimeObj(o)) {
				if (document.getElementById(o.name.replace(/_time$/,""))){
					document.getElementById(o.name.replace(/_time$/,"")).value = document.getElementById(o.name.replace(/_time$/,"")).value.replace(/\./g,"");
				}
				if (!sm_CheckTimeElement(o, sm_GetTimeObj)) {
					errmsg += "* " + o.value + "\n";
				}
			} else if (sm_IsRangeObj(o)) {
				if (!sm_CheckRangeElement(o, sm_GetRangeObj)) {
					errmsg += "* " + o.name + " is restricted to " + sm_StripCRLF(o.value) + "\n";
				}
			} else if (sm_IsEmailObj(o)) {
				if (!sm_CheckEmailElement(o, sm_GetEmailObj)) {
					errmsg += "* " + o.value + "\n";
				}
			} else if (sm_IsMultiEmailsObj(o)) {
				if (!sm_CheckMultiEmailsElement(o, sm_GetMultiEmailsObj)) {
					errmsg += "* " + o.value + "\n";
				}
			}
		}
	}
	if (errmsg.length > 0) {
		window.alert(errmsg);
		return false;
	}
	return true;
}
//-->
</script>

			<script language="JavaScript" type="text/javascript">
			<!--
			var smm_eforms_toggle_other_to_init = new Array();
			function smm_eforms_toggle_other_init() {
				var i = 0;
				var o = null;
				var strFEType = null;
				var bCallToggler = null;
				for (i = 0; i < smm_eforms_toggle_other_to_init.length; i++) {
					o = document.getElementById(smm_eforms_toggle_other_to_init[i]);
					if (o != null) {
						if (o.type) {
							strFEType = o.type;
							switch (strFEType) {
								case "radio":
								{
									bCallToggler = o.checked;
									break;
								}
								case "checkbox":
								{
									bCallToggler = (o.value.toLowerCase() == 'other');
									break;
								}
								case "select-one": {
									bCallToggler = true;
									break;
								}
								default: {
									bCallToggler = false;
									break;
								}
							}
						} else {
							strFEType = "";
						}
						if (bCallToggler) {
							smm_eforms_toggle_other(o);
						}
					}
				}
				return true;
			}
			var smm_eforms_displayEformsForm_onLoadBackup = null;
			function smm_eforms_displayEformsForm_onLoad() {
				if (smm_eforms_displayEformsForm_onLoadBackup != null) {
					smm_eforms_displayEformsForm_onLoadBackup();
				}
				smm_eforms_toggle_other_init();
				return true;
			}
			if (window.onload && window.onload != null) {
				smm_eforms_displayEformsForm_onLoadBackup = window.onload;
			}
			window.onload = smm_eforms_displayEformsForm_onLoad;
			function smm_eforms_toggle_other(oFormElement) {
				var strSourceName = oFormElement.name;
				var strSourceId = strSourceName + "_other";
				var strTargetId = strSourceId + "_txt";
				var oForm = oFormElement.form;
				var oSource = oForm[strSourceId];
				var oTarget = oForm[strTargetId];
				var oTartgetReq = oForm[strTargetId + "_required"];
				var strFEType = oFormElement.type;
				if (strFEType=='checkbox' || strFEType=='radio'){
					if (oSource.checked){
						oTarget.disabled=false;
						oTartgetReq.name=strTargetId + '_required';
					} else {
						oTarget.value='';
						oTarget.disabled=true;
						oTartgetReq.name=strTargetId + '_notreq';
					}
				} else {
					oSource = oForm[strSourceName];
					if (oSource.options[oSource.options.length-1].selected){
						oTarget.disabled=false;
						oTartgetReq.name=strTargetId + '_required';
					} else {
						oTarget.value='';
						oTarget.disabled=true;
						oTartgetReq.name=strTargetId + '_notreq';
					}
				}
			}
			//-->
			</script>
		<form name="eform" method="post" action="http://www.harborhospital.org/form.cfm?xyzpdqabc=0&amp;id=556161&amp;action=submiteform" onSubmit="return (sm_ValidateForm(this) && sm_removeALLrequiredhiddenfields(this));" class="metadetail">
		<table class="metadetail">
			<tr class="metadetail">
				<td class="metadetail" colspan="2"><img src=images/RotatorCuffFlyer.gif alt=Rotator Cuff Fact Sheet class=right />Our ortho kit includes information on rotator cuff tears, a free hot/cold pack and more! Just complete the form below.<br><br><span class=red>Offer only for residents of the states listed below, with a valid zip code. While supplies last.</span><br><br><br><br></td>
			</tr>
			<tr class="metadetail">
				<td class="metadetail" colspan="2"><span class="required">
				* Indicates required information</span></td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">First Name&nbsp;<span class="required">*</span>&nbsp;</th>
				<td class="metadetail">
					<input type="Text" name="eformField_1" class="metadetail" size="35" value="">
					<input type="Hidden" name="eformField_1_required" class="metadetail" value="First Name is required.">
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Last Name&nbsp;<span class="required">*</span>&nbsp;</th>
				<td class="metadetail">
					<input type="Text" name="eformField_2" class="metadetail" size="35" value="">
					<input type="Hidden" name="eformField_2_required" class="metadetail" value="Last Name is required.">
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Street Address 1&nbsp;<span class="required">*</span>&nbsp;</th>
				<td class="metadetail">
					<input type="Text" name="eformField_3" class="metadetail" size="35" value="">
					<input type="Hidden" name="eformField_3_required" class="metadetail" value="Street Address 1 is required.">
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Street Address 2&nbsp;</th>
				<td class="metadetail">
					<input type="Text" name="eformField_4" class="metadetail" size="35" value="">
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">City&nbsp;<span class="required">*</span>&nbsp;</th>
				<td class="metadetail">
					<input type="Text" name="eformField_5" class="metadetail" size="35" value="">
					<input type="Hidden" name="eformField_5_required" class="metadetail" value="City is required.">
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">State&nbsp;<span class="required">*</span>&nbsp;</th>
				<td class="metadetail">
					<select name="eformField_6" id="eformField_6" class="metadetail">
						<option value="Maryland" selected>Maryland</option>
						<option value="DC">DC</option>
						<option value="Delaware">Delaware</option>
						<option value="Virginia">Virginia</option>
						<option value="Pennsylvania">Pennsylvania</option>
					</select>
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Zip&nbsp;<span class="required">*</span>&nbsp;</th>
				<td class="metadetail">
					<input type="Text" name="eformField_7" class="metadetail" size="35" value="">
					<input type="Hidden" name="eformField_7_required" class="metadetail" value="Zip is required.">
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Date of Birth (mm/dd/yyyy)&nbsp;<span class="required">*</span>&nbsp;</th>
				<td class="metadetail">
					<input type="Text" name="eformField_8" class="metadetail" size="35" value="">
					<input type="Hidden" name="eformField_8_required" class="metadetail" value="Date of Birth (mm/dd/yyyy) is required.">
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Phone&nbsp;</th>
				<td class="metadetail">
					<input type="Text" name="eformField_9" class="metadetail" size="35" value="">
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Email&nbsp;</th>
				<td class="metadetail">
					<input type="Text" name="eformField_10" class="metadetail" size="35" value="">
					  
					<input type="Hidden" name="eformField_10_email" class="metadetail" value="Email must be a valid email address.">
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Would you like to receive our quarterly magazine?&nbsp;<span class="required">*</span>&nbsp;</th>
				<td class="metadetail">
					<span style="white-space:nowrap;"><input type="radio" name="eformField_11" id="eformField_11_1" style="{border:0;}" value="yes">
					<label for="eformField_11_1" class="metadetail">yes</label></span>
					<span style="white-space:nowrap;"><input type="radio" name="eformField_11" id="eformField_11_2" style="{border:0;}" value="no" checked>
					<label for="eformField_11_2" class="metadetail">no</label></span>
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">How did you hear about us?&nbsp;</th>
				<td class="metadetail">
					<select name="eformField_12" id="eformField_12" class="metadetail" onChange="return smm_eforms_toggle_other(this);">
						<option value="" selected></option>
						<option value="TV - WMAR - Channel 2">TV - WMAR - Channel 2</option>
						<option value="TV - WBAL - Channel 11">TV - WBAL - Channel 11</option>
						<option value="TV - WJZ - Channel 13">TV - WJZ - Channel 13</option>
						<option value="Web - abc2news.com">Web - abc2news.com</option>
						<option value="Web - wbalchannel.com">Web - wbalchannel.com</option>
						<option value="Web - wjz.com">Web - wjz.com</option>
						<option value="Web - MedStar/hospital site">Web - MedStar/hospital site</option>
						<option value="Radio - WBAL">Radio - WBAL</option>
						<option value="Radio - WYPR">Radio - WYPR</option>
						<option value="Hospital Newsletter">Hospital Newsletter</option>
						<option value="Hospital E-newsletter">Hospital E-newsletter</option>
						<option value="Baltimore Sun">Baltimore Sun</option>
						<option value="baltimoresun.com">baltimoresun.com</option>
						<option value="Community Newspaper">Community Newspaper</option>
						<option value="Doctor">Doctor</option>
						<option value="Word of Mouth">Word of Mouth</option>
						<option value="Electronic Messaging Billboard/Sign">Electronic Messaging Billboard/Sign</option><option value='Other'>Other</option>
					</select>
					<div class="metanew">
						<p class="metanew">
							If Other, please specify:<br>
							<textarea cols="30" rows="3" name="eformField_12_other_txt" disabled class="metadetail"></textarea>
						</p>
					</div>
					<script language="JavaScript" type="text/javascript"><!--
					smm_eforms_toggle_other_to_init[smm_eforms_toggle_other_to_init.length] = "eformField_12";
					//--></script>
					<input type="hidden" name="eformField_12_other_txt_required" value='Please provide further details to your answer: Other.' disabled>
				</td>
			</tr>
			<tr class="metadetail">
				<th class="metadetail">&nbsp;</th>
				<td class="metadetail">
					<input type="submit" name="submit" value="Submit" class="metadetail">
				</td>
			</tr>
			<tr class="metadetail">
				<td class="metadetail" colspan="2"><br><span class=footnote>As always, Harbor Hospital and its parent company, MedStar Health, respect your privacy. The information you submit is used for internal purposes only to help guide us in developing health information relevant to your needs.</span></td>
			</tr>
		</table>
		</form>
	
	

 



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