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Dr. Todd Lepine MD :: Thank You! <body> <head> <script language="JavaScript"> function verify() { var themessage = "Please fix: "; if (document.form.realname.value=="") { themessage = themessage + " - Your Name"; } if (document.form.email.value=="") { themessage = themessage + " - Email"; } if (document.form.comment.value=="") { themessage = themessage + " - Comment"; } //alert if fields are empty and cancelform submit if (themessage == "Please fix: ") { document.form.submit(); } else { alert(themessage); return false; } } </script> </head> <div id="siteframe"> <div> <img src="/drtl/images/logo.jpg" alt="" border="0"></div> <div id="header2" align="right"> <div id="mainNav"> <b>Dr. Todd LePine, M.D. </b> </div> </div> <div id="header3"> <img src="http://www.drlepine.com/drtl/images/.jpg" width="750" height="80" alt="" border="0"> </div> <div id="header4" align="center"> <div class="mainNav"> | Home | Services | Consultations | Products | Resources | News | FAQ | About | Contact | </div> </div> <div id="content"> <table width="748" border="0" cellspacing="0" cellpadding="0"> <tr> <td valign="top" width="227" background="/drtl/images/background-main.jpg"><img src="/drtl/images/corner.gif" alt="" width="227" height="40" border="0"></td> <td colspan="2" background="/drtl/images/shadow1.gif"></td> </tr> <tr> <td valign="top" width="227" background="/drtl/images/background-main.jpg"> <div id="navhead"> In This Section </div> <div class="subnav"> </div> <br><br> <div class="contact"> <br> Todd R. LePine, MD<br>
The Village Commons<br> 23 College Street<br> South Hadley, MA 01075<br> (413) 303-9864<br><br> <a href="mailto:toddlepine@drlepine.com" >Email Dr. LePine </a> <br/> </div> </td> <td colspan="2"> <div class='sechead1'> Thank You! </div> <div class="mainannounce"> <br><br> </div> <div> <table class="left" width="448" border="0" cellspacing="0" cellpadding="0"> <tr> <td colspan="2">For more information, please complete the following form<br> (required fields are bold).<br/> <br/> </td> </tr> <tr> <td colspan="2"></td> </tr> <tr> <td rowspan="4" colspan="2"> <form action="http://www.drlepine.com/cgi-bin/formmail/FormMail.pl" method="post" name="form"> <table width="439" border="0" cellspacing="0" cellpadding="0"> <tr> <td width="157"> <input type="hidden" name="subject" value="drlepine.com Inquiry" /> <input type="hidden" name="env_report" value="REMOTE_HOST, REMOTE_ADDR,HTTP_USER_AGENT" /> <input type="hidden" name="redirect" value="http://www.drlepine.com/drtl/contact/thanks.shtml" /> <input type="hidden" name="recipient" value="info@drlepine.com" /></td> <td width="138"></td> <td></td> </tr> <tr > <td class="first" width="157"><b>First and Last Name</b></td> <td class="firstr" colspan="2"><input type="text" name="realname" size="40" /></td> </tr> <tr> <td class="conttop" width="157">Title</td> <td class="contr" colspan="2"><input type="text" name="title" size="40" /></td> </tr> <tr > <td class="conttop" width="157">Company</td> <td class="contr" colspan="2"><input type="text" name="company" size="40" /></td> </tr> <tr > <td class="conttop" width="157">Street Address</td> <td class="contr" colspan="2"><textarea name="street" rows="2" cols="40"></textarea></td> </tr> <tr> <td class="conttop" width="157">State/Province</td> <td class="contr" colspan="2"><input type="text" name="state" value="" size="20" /></td> </tr> <tr> <td class="conttop" width="157">Zip/Postal Code</td> <td class="contr" colspan="2"><input type="text" name="zip" value="" size="20" /></td> </tr> <tr> <td class="conttop" width="157">Country</td> <td class="contr" colspan="2"><input type="text" name="country" size="40" /></td> </tr> <tr> <td class="conttop" width="157">Evening Phone</td> <td class="contr" colspan="2"><input type="text" name="eveningphone" size="15" /></td> </tr> <tr > <td class="conttop" width="157">Work/Daytime Phone </td> <td class="contr" colspan="2"><input type="text" name="dayphone" size="15" /></td> </tr> <tr> <td class="conttop" width="157">Fax Phone</td> <td class="contr" colspan="2"><input type="text" name="fax" size="15" /></td> </tr> <tr > <td class="conttop" width="157"><b>Email Address</b></td> <td class="contr" colspan="2"><input type="text" name="email" size="40" /></td> </tr> <tr > <td class="conttop" width="157">How did you hear about us?</td> <td class="contr" colspan="2"><input type="text" name="how_did_you_hear" value="" size="40" /></td> </tr> <tr > <td class="conttop" valign="top" width="157" height="95"><br/> <b>Comments</b></td> <td class="contr" colspan="2" valign="top" height="95"><textarea name="comment" rows="6" cols="40"></textarea></td> </tr> <tr> <td colspan="3" valign="top" height="16"> </td> </tr> <tr> <td width="157"></td> <td width="138"> <div align="center"> <input title="Send it" onclick="verify();" type="button" value="Submit" /></div> </td> <td align="right"> <div align="left"> <input type="reset" value="Clear" /></div> </td> </tr> </table> </form> </td> </tr> <tr height="25"> </tr> <tr> </tr> <tr> </tr> </table> </div> </td> </tr> </table> <div id="bottombar"> <div id="footer">| Contact Us | Privacy Policy | Terms of Use | Web Designer |
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© 2005 Dr. Todd LePine, MD. All Rights Reserved.