document.writeln("<div style=\"position:relative; display:block;\"><div align=\"center\" style=\"position:absolute; top:-550px; left:370px;\">");
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document.writeln("<tr><td align=\"center\"><a href=\"http://livechat.boldchat.com/aid/2611627403659895218/bc.chat?cwdid=6017834491416787697\" target=\"_blank\" onClick=\"window.open(\'http://livechat.boldchat.com/aid/2611627403659895218/bc.chat?cwdid=6017834491416787697&amp;url=\' + escape(document.location.href), \'Chat8628327199049472835\', \'toolbar=0,scrollbars=1,location=0,statusbar=0,menubar=0,resizable=1,width=640,height=480\');return false;\"><img alt=\"Live chat by BoldChat\" src=\"http://cbi.boldchat.com/aid/2611627403659895218/bc.cbi?cbdid=7433766030261678149\" border=\"0\" width=\"144\" /></a></td></tr>");
document.writeln("<tr><td align=\"center\"><font size=\"1\" face=\"Arial\"><a href=\"http://www.boldchat.com\" style=\"text-decoration: none\"><font color=\"white\">Live chat by </font><b><font color=\"#AD3100\">Bold</font><font color=\"#003163\">chat</font></b></a></font></td></tr>");
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if (document.location.href.indexOf("/form.html") < 0)
{
document.writeln("<div style=\"color:#97BFFA;font-size:20px;font-weight:bold;font-family:Arial, Helvetica, sans-serif;text-align:center;\">Do I Have<br />A Case?</div><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=\"company_from\" type=\"hidden\" value=\"Nadrich Law PPH Lawyer\" />");
document.writeln("<input name=\"thankyoupage\" type=\"hidden\" value=\"http://www.pph-lawyer.net/thanks.html\"/>	");
document.writeln("<input name=\"product7\" 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 />");
document.writeln("<input class=\"texto\" size=\"18\" name=\"homephone\" style=\"width: 130px;\" /></td>");
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("<tr>");
document.writeln("<td class=\"titulosR\" align=\"left\">Comments:<br />");
document.writeln("<textarea name=\"comments\" cols=\"15\" rows=\"3\" class=\"texto\" id=\"comments\" style=\"width: 130px;\"></textarea></td>");
document.writeln("</tr>");
document.writeln("<tr>");
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>");
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