document.writeln("  <span class=\"sinchaku\">下記のフォームに必要事項をご記入の上、症状やご相談されたい内容をご記入ください。 <\/span> <br>");
document.writeln("  <span class=\"STYLE15\"> （※） の項目は入力必須です<\/span>");
document.writeln("  <div id=\"mail\">");
document.writeln("<table border=\"0\" cellpadding=\"2\" cellspacing=\"2\" bgcolor=\"#BBE8FF\">");
document.writeln("                        <tr>");
document.writeln("                          <td colspan=\"3\" align=\"center\" bgcolor=\"#FFFFFF\"><strong class=\"sinchaku\">患者様情報<\/strong> <\/td>");
document.writeln("                        <\/tr>");
document.writeln("                        <tr>");
document.writeln("                          <td valign=\"top\" bgcolor=\"#FFFFFF\">患者様のお名前<span class=\"hide\"> (<span class=\"require_text\">※<\/span>) <\/span><\/td>");
document.writeln("                          <td width=\"12\" rowspan=\"7\" valign=\"top\" bgcolor=\"#FFFFFF\"><p align=\"center\">&nbsp;<\/p>                            <p align=\"center\">&nbsp;<\/p>                            <p align=\"center\">&nbsp;<\/p>                            <p align=\"center\">&nbsp;<\/p>                            <p align=\"center\">&nbsp;<\/p>                            <p align=\"center\">&nbsp;<\/p><\/td>");
document.writeln("                          <td width=\"355\" valign=\"top\" bgcolor=\"#FFFFFF\" class=\"sinchaku\"><span class=\"hide\">姓　 ");
document.writeln("          <\/span>");
document.writeln("                            <input type=\"text\" maxlength=\"14\" size=\"10\" name=\"name1\" id=\"name1\" class=\"require\" \/>");
document.writeln("          <span class=\"hide\">名　 ");
document.writeln("          <\/span><input type=\"text\" maxlength=\"14\" size=\"10\" name=\"name2\" id=\"name2\" class=\"require\" \/>");
document.writeln("          <span class=\"hide small\">例) 新橋　太郎<\/span><\/td>");
document.writeln("                        <\/tr>");
document.writeln("                        <tr>");
document.writeln("                          <td valign=\"top\" bgcolor=\"#FFFFFF\">フリガナ<span class=\"hide\"> (<span class=\"require_text\">※<\/span>)<\/span><\/td>");
document.writeln("                          <td valign=\"top\" bgcolor=\"#FFFFFF\" class=\"sinchaku\"><span class=\"hide\">セイ");
document.writeln("          <\/span>");
document.writeln("                            <input type=\"text\" maxlength=\"14\" size=\"10\" name=\"furi1\" id=\"furi1\" class=\"require\" \/>");
document.writeln("          <span class=\"hide\">メイ&nbsp;");
document.writeln("          <\/span><input type=\"text\" maxlength=\"14\" size=\"10\" name=\"furi2\" id=\"furi2\" class=\"require\" \/>");
document.writeln("          <span class=\"hide small\">例)シンバシ　タロウ<\/span><\/td>");
document.writeln("                        <\/tr>");
document.writeln("                        <tr>");
document.writeln("                          <td valign=\"top\" bgcolor=\"#FFFFFF\">メールアドレス<span class=\"hide\">(<span class=\"require_text\">※<\/span>) <\/span><\/td>");
document.writeln("                          <td align=\"left\" valign=\"top\" bgcolor=\"#FFFFFF\"><input type=\"text\" maxlength=\"40\" size=\"22\" name=\"email\" id=\"email\" class=\"require email\" \/>");
document.writeln("        <span class=\"hide small\">例)    ginza@nannbyou.com <\/span><\/td>");
document.writeln("                        <\/tr>");
document.writeln("                        <tr>");
document.writeln("                          <td valign=\"top\" bgcolor=\"#FFFFFF\">生年月日（西暦）<span class=\"hide\">(<span class=\"require_text\">※<\/span>)<\/span><\/td>");
document.writeln("                          <td align=\"left\" valign=\"top\" bgcolor=\"#FFFFFF\" class=\"sinchaku\">19");
document.writeln("                            <input type=\"text\" maxlength=\"2\" size=\"2\" name=\"year\" id=\"year\" class=\"require num\" \/>");
document.writeln("年");
document.writeln("<select name=\"month\" id=\"month\" class=\"require\">");
document.writeln("  <option><\/option>");
document.writeln("  <option value=\"01\">01 <\/option>");
document.writeln("  <option value=\"02\">02 <\/option>");
document.writeln("  <option value=\"03\">03 <\/option>");
document.writeln("  <option value=\"04\">04 <\/option>");
document.writeln("  <option value=\"05\">05 <\/option>");
document.writeln("  <option value=\"06\">06 <\/option>");
document.writeln("  <option value=\"07\">07 <\/option>");
document.writeln("  <option value=\"08\">08 <\/option>");
document.writeln("  <option value=\"09\">09 <\/option>");
document.writeln("  <option value=\"10\">10 <\/option>");
document.writeln("  <option value=\"11\">11 <\/option>");
document.writeln("  <option value=\"12\">12 <\/option>");
document.writeln("<\/select>");
document.writeln("月");
document.writeln("<select name=\"day\" id=\"day\" class=\"require\">");
document.writeln("  <option><\/option>");
document.writeln("  <option value=\"01\">01 <\/option>");
document.writeln("  <option value=\"02\">02 <\/option>");
document.writeln("  <option value=\"03\">03 <\/option>");
document.writeln("  <option value=\"04\">04 <\/option>");
document.writeln("  <option value=\"05\">05 <\/option>");
document.writeln("  <option value=\"06\">06 <\/option>");
document.writeln("  <option value=\"07\">07 <\/option>");
document.writeln("  <option value=\"08\">08 <\/option>");
document.writeln("  <option value=\"09\">09 <\/option>");
document.writeln("  <option value=\"10\">10 <\/option>");
document.writeln("  <option value=\"11\">11 <\/option>");
document.writeln("  <option value=\"12\">12 <\/option>");
document.writeln("  <option value=\"13\">13 <\/option>");
document.writeln("  <option value=\"14\">14 <\/option>");
document.writeln("  <option value=\"15\">15 <\/option>");
document.writeln("  <option value=\"16\">16 <\/option>");
document.writeln("  <option value=\"17\">17 <\/option>");
document.writeln("  <option value=\"18\">18 <\/option>");
document.writeln("  <option value=\"19\">19 <\/option>");
document.writeln("  <option value=\"20\">20 <\/option>");
document.writeln("  <option value=\"21\">21 <\/option>");
document.writeln("  <option value=\"22\">22 <\/option>");
document.writeln("  <option value=\"23\">23 <\/option>");
document.writeln("  <option value=\"24\">24 <\/option>");
document.writeln("  <option value=\"25\">25 <\/option>");
document.writeln("  <option value=\"26\">26 <\/option>");
document.writeln("  <option value=\"27\">27 <\/option>");
document.writeln("  <option value=\"28\">28 <\/option>");
document.writeln("  <option value=\"29\">29 <\/option>");
document.writeln("  <option value=\"30\">30 <\/option>");
document.writeln("  <option value=\"31\">31 <\/option>");
document.writeln("<\/select>");
document.writeln("日 <span class=\"hide small\">半角数字<\/span><\/td>");
document.writeln("                        <\/tr>");
document.writeln("                        <tr>");
document.writeln("                          <td valign=\"top\" bgcolor=\"#FFFFFF\">性別<\/td>");
document.writeln("                          <td valign=\"top\" bgcolor=\"#FFFFFF\" class=\"sinchaku\">");
document.writeln("        <input type=\"radio\" checked=\"checked\" name=\"sex\" value=\"男性\" \/>");
document.writeln("        <span class=\"hide\">男性 <\/span>");
document.writeln("        <input type=\"radio\" name=\"sex\" value=\"女性\" \/>");
document.writeln("        <span class=\"hide\">女性<\/span><\/td>");
document.writeln("                        <\/tr>");
document.writeln("                        <tr>");
document.writeln("                          <td width=\"134\" valign=\"top\" bgcolor=\"#FFFFFF\">電話番号<span class=\"hide\">(<span class=\"require_text\">※<\/span>)<\/span><\/td>");
document.writeln("                          <td valign=\"top\" bgcolor=\"#FFFFFF\" class=\"sinchaku\">");
document.writeln("        <input type=\"text\" size=\"30\" name=\"tel\" id=\"tel\" class=\"require\" \/>");
document.writeln("        <span class=\"hide small\">半角数字 例) 03-1111-2222<\/span><\/td>");
document.writeln("                        <\/tr>");
document.writeln("                        <tr>");
document.writeln("                          <td width=\"134\" valign=\"top\" bgcolor=\"#FFFFFF\">症状及び<br \/>");
document.writeln("ご相談内容<\/td>");
document.writeln("                          <td valign=\"top\" bgcolor=\"#FFFFFF\"><textarea rows=\"12\" cols=\"40\" name=\"comment\"><\/textarea><\/td>");
document.writeln("                        <\/tr>");
document.writeln("												<tr>");
document.writeln("                          <td colspan=\"3\" align=\"center\" valign=\"middle\" bgcolor=\"#FFFFFF\"><input type=\"hidden\" name=\"submit_content\" id=\"submit_content\" \/><input type=\"hidden\" value=\"お問い合わせ\" name=\"subject\" id=\"subject\" \/><\/td>");
document.writeln("                          <\/tr>");
document.writeln("                          ");
document.writeln("						<tr class=\"hide\">");
document.writeln("                          <td colspan=\"3\" align=\"center\" valign=\"middle\" bgcolor=\"#FFFFFF\"><input type=\"submit\" value=\"送信\" name=\"submit\" \/>");
document.writeln("                              &nbsp;&nbsp;");
document.writeln("                              <input type=\"reset\" value=\"リセット\" name=\"reset\" \/>");
document.writeln("                            <\/td>");
document.writeln("                          <\/tr>");
document.writeln("                      <\/table>")
document.writeln("  <\/div>");