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'<table width="100%" border="0" cellspacing="0" cellpadding="0" style="margin-top: 8px;">',
'<tr>',
'<td width="1" valign="top" colspan="2" nowrap>Treatments&nbsp;desired:&nbsp;</td>',
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'<tr>',
'<td colspan="2"><textarea name="Treatments" cols="50" rows="3" wrap="virtual" class="form-textarea"></textarea>',
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'</tr>',
'<tr><td>Preferred Time: </td>',
'<td height="26"><select name="time_hour" size="1" class="form-text"><option value=""><option value="09">09</option><option value="10">10</option><option value="11">11</option><option value="12">12</option><option value="13">13</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="17">17</option><option value="18">18</option><option value="19">19</option><option value="20">20</option><option value="21">21</option></select> hour',
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'<option value="00" >00</option>',
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'<option value="45" >45</option>',
'',
'</select> min</td>',
'</tr>',
'</table>',
'<table width="100%" border="0" cellspacing="0" cellpadding="0">',
'<tr>',
'<td><br><b>Your contact information</b></td>',
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'</table>',
'<table border="0" style="margin-top: 5px;">',
'<tr>',
'<td>* Title:</td>',
'<td rowspan="2" class="form-cell" nobreak>&nbsp;</td>',
'<td>* First Name:</td>',
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'<td><input type="text" name="Salutation" class="form-text" style="width: 50px"></td>',
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'</table>',
'<br>',
'* E-mail Address:<br>',
'<input type="text" name="Email" class="form-text" size="55">	  <br>',
'<br>',
'<table style="margin-top: 7px;" cellpadding="0" cellspacing="0" border="0">',
'<tr>',
'<td align="left">* Preferred Phone Number:',
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'<tr valign="top">',
'<td class="form-cell"><input name="Phone" type="text" maxlength="16" class="form-text" size="55"></td>',
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'</table>',
'<span style="font-size: 9px">Please include country and area codes with phone number.</span></td>',
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'</table>',
'<br>',
'* Address:<br>',
'<textarea name="Address" cols="50" rows="3" wrap="virtual" class="form-textarea"></textarea>',
'<table style="margin-top: 7px;" border="0">',
'<tr>',
'<td>* Country:</td>',
'</tr>',
'<tr>',
'<td><select name="Country" size="1" class="form-dropdown">',
'<option>Choose a Country</option>',
'<option value="AF,Afghanistan">Afghanistan',
'<option value="AL,Albania">Albania',
'<option value="DZ,Algeria">Algeria',
'<option value="AS,American Samoa">American Samoa',
'<option value="AD,Andorra">Andorra',
'<option value="AO,Angola">Angola',
'<option value="AI,Anguilla">Anguilla',
'<option value="AQ,Antarctica">Antarctica',
'<option value="AG,Antigua/Barbuda">Antigua/Barbuda',
'<option value="AR,Argentina">Argentina',
'<option value="AM,Armenia">Armenia',
'<option value="AW,Aruba">Aruba',
'<option value="AU,Australia">Australia',
'<option value="AT,Austria">Austria',
'<option value="AZ,Azerbaijan">Azerbaijan',
'<option value="BS,Bahamas">Bahamas',
'<option value="BH,Bahrain">Bahrain',
'<option value="BD,Bangladesh">Bangladesh',
'<option value="BB,Barbados">Barbados',
'<option value="BY,Belarus">Belarus',
'<option value="BE,Belgium">Belgium',
'<option value="BZ,Belize">Belize',
'<option value="BJ,Benin">Benin',
'<option value="BM,Bermuda">Bermuda',
'<option value="BT,Bhutan">Bhutan',
'<option value="BO,Bolivia">Bolivia',
'<option value="BA,Bosnia/Herzegovinia">Bosnia/Herzegovinia',
'<option value="BW,Botswana">Botswana',
'<option value="BV,Bouvet Island">Bouvet Island',
'<option value="BR,Brazil">Brazil',
'<option value="IO,British Indian Ocean Territory">British Indian Ocean Territory',
'<option value="BN,Brunei Darussalam">Brunei Darussalam',
'<option value="BG,Bulgaria">Bulgaria',
'<option value="BF,Burkina Faso">Burkina Faso',
'<option value="BI,Burundi">Burundi',
'<option value="KH,Cambodia">Cambodia',
'<option value="CM,Cameroon">Cameroon',
'<option value="CA,Canada">Canada',
'<option value="CV,Cape Verde">Cape Verde',
'<option value="KY,Cayman Islands">Cayman Islands',
'<option value="CF,Central African Republic">Central African Republic',
'<option value="TD,Chad">Chad',
'<option value="CL,Chile">Chile',
'<option value="CN,China">China',
'<option value="CX,Christmas Island">Christmas Island',
'<option value="CC,Cocos (Keeling) Islands">Cocos (Keeling) Islands',
'<option value="CO,Colombia">Colombia',
'<option value="KM,Comoros">Comoros',
'<option value="CG,Congo">Congo',
'<option value="CD,Congo, DR Of The">Congo, DR Of The',
'<option value="CK,Cook Islands">Cook Islands',
'<option value="CR,Costa Rica">Costa Rica',
'<option value="CI,Cote D\'ivoire">Cote D\'ivoire',
'<option value="HR,Croatia">Croatia',
'<option value="CU,Cuba">Cuba',
'<option value="CY,Cyprus">Cyprus',
'<option value="CZ,Czech Republic">Czech Republic',
'<option value="DK,Denmark">Denmark',
'<option value="DJ,Djibouti">Djibouti',
'<option value="DM,Dominica">Dominica',
'<option value="DO,Dominican Republic">Dominican Republic',
'<option value="TP,East Timor">East Timor',
'<option value="EC,Ecuador">Ecuador',
'<option value="EG,Egypt">Egypt',
'<option value="SV,El Salvador">El Salvador',
'<option value="GQ,Equatorial Guinea">Equatorial Guinea',
'<option value="ER,Eritrea">Eritrea',
'<option value="EE,Estonia">Estonia',
'<option value="ET,Ethiopia">Ethiopia',
'<option value="FK,Falkland Islands">Falkland Islands',
'<option value="FO,Faroe Islands">Faroe Islands',
'<option value="FJ,Fiji">Fiji',
'<option value="FI,Finland">Finland',
'<option value="FR,France">France',
'<option value="FX,France, Metropolitan">France, Metropolitan',
'<option value="GF,French Guiana">French Guiana',
'<option value="PF,French Polynesia">French Polynesia',
'<option value="TF,French Southern Territories">French Southern Territories',
'<option value="GA,Gabon">Gabon',
'<option value="GM,Gambia">Gambia',
'<option value="GE,Georgia">Georgia',
'<option value="DE,Germany">Germany',
'<option value="GH,Ghana">Ghana',
'<option value="GI,Gibraltar">Gibraltar',
'<option value="GR,Greece">Greece',
'<option value="GL,Greenland">Greenland',
'<option value="GD,Grenada">Grenada',
'<option value="GP,Guadeloupe">Guadeloupe',
'<option value="GU,Guam">Guam',
'<option value="GT,Guatemala">Guatemala',
'<option value="GN,Guinea">Guinea',
'<option value="GW,Guinea-Bissau">Guinea-Bissau',
'<option value="GY,Guyana">Guyana',
'<option value="HT,Haiti">Haiti',
'<option value="HM,Heard And Mcdonald Islands">Heard And Mcdonald Islands',
'<option value="HN,Honduras">Honduras',
'<option value="HK,Hong Kong">Hong Kong',
'<option value="HU,Hungary">Hungary',
'<option value="IS,Iceland">Iceland',
'<option value="IN,India">India',
'<option value="ID,Indonesia">Indonesia',
'<option value="IR,Iran">Iran',
'<option value="IQ,Iraq">Iraq',
'<option value="IE,Ireland">Ireland',
'<option value="IL,Israel">Israel',
'<option value="IT,Italy">Italy',
'<option value="JM,Jamaica">Jamaica',
'<option value="JP,Japan">Japan',
'<option value="JO,Jordan">Jordan',
'<option value="KZ,Kazakhstan">Kazakhstan',
'<option value="KE,Kenya">Kenya',
'<option value="KI,Kiribati">Kiribati',
'<option value="KP,Korea, DPR Of">Korea, DPR Of',
'<option value="KR,Korea, Republic Of">Korea, Republic Of',
'<option value="KW,Kuwait">Kuwait',
'<option value="KG,Kyrgyzstan">Kyrgyzstan',
'<option value="LA,Laos">Laos',
'<option value="LV,Latvia">Latvia',
'<option value="LB,Lebanon">Lebanon',
'<option value="LS,Lesotho">Lesotho',
'<option value="LR,Liberia">Liberia',
'<option value="LY,Libyan Arab Jamahiriya">Libyan Arab Jamahiriya',
'<option value="LI,Liechtenstein">Liechtenstein',
'<option value="LT,Lithuania">Lithuania',
'<option value="LU,Luxembourg">Luxembourg',
'<option value="MO,Macau">Macau',
'<option value="MK,Macedonia, FYR Of">Macedonia, FYR Of',
'<option value="MG,Madagascar">Madagascar',
'<option value="MW,Malawi">Malawi',
'<option value="MY,Malaysia">Malaysia',
'<option value="MV,Maldives">Maldives',
'<option value="ML,Mali">Mali',
'<option value="MT,Malta">Malta',
'<option value="MH,Marshall Islands">Marshall Islands',
'<option value="MQ,Martinique">Martinique',
'<option value="MR,Mauritania">Mauritania',
'<option value="MU,Mauritius">Mauritius',
'<option value="YT,Mayotte">Mayotte',
'<option value="MX,Mexico">Mexico',
'<option value="FM,Micronesia, FS Of">Micronesia, FS Of',
'<option value="MD,Moldova, Republic Of">Moldova, Republic Of',
'<option value="MC,Monaco">Monaco',
'<option value="MN,Mongolia">Mongolia',
'<option value="MS,Montserrat">Montserrat',
'<option value="MA,Morocco">Morocco',
'<option value="MZ,Mozambique">Mozambique',
'<option value="MM,Myanmar">Myanmar',
'<option value="NA,Namibia">Namibia',
'<option value="NR,Nauru">Nauru',
'<option value="NP,Nepal">Nepal',
'<option value="NL,Netherlands">Netherlands',
'<option value="AN,Netherlands Antilles">Netherlands Antilles',
'<option value="NC,New Caledonia">New Caledonia',
'<option value="NZ,New Zealand">New Zealand',
'<option value="NI,Nicaragua">Nicaragua',
'<option value="NE,Niger">Niger',
'<option value="NG,Nigeria">Nigeria',
'<option value="NU,Niue">Niue',
'<option value="NF,Norfolk Island">Norfolk Island',
'<option value="MP,Northern Mariana Islands">Northern Mariana Islands',
'<option value="NO,Norway">Norway',
'<option value="OM,Oman">Oman',
'<option value="PK,Pakistan">Pakistan',
'<option value="PW,Palau">Palau',
'<option value="PA,Panama">Panama',
'<option value="PG,Papua New Guinea">Papua New Guinea',
'<option value="PY,Paraguay">Paraguay',
'<option value="PE,Peru">Peru',
'<option value="PH,Philippines">Philippines',
'<option value="PN,Pitcairn">Pitcairn',
'<option value="PL,Poland">Poland',
'<option value="PT,Portugal">Portugal',
'<option value="PR,Puerto Rico">Puerto Rico',
'<option value="QA,Qatar">Qatar',
'<option value="RE,Reunion">Reunion',
'<option value="RO,Romania">Romania',
'<option value="RU,Russian Federation">Russian Federation',
'<option value="RW,Rwanda">Rwanda',
'<option value="KN,Saint Kitts And Nevis">Saint Kitts And Nevis',
'<option value="LC,Saint Lucia">Saint Lucia',
'<option value="WS,Samoa">Samoa',
'<option value="SM,San Marino">San Marino',
'<option value="ST,Sao Tome And Principe">Sao Tome And Principe',
'<option value="SA,Saudi Arabia">Saudi Arabia',
'<option value="SN,Senegal">Senegal',
'<option value="SC,Seychelles">Seychelles',
'<option value="SL,Sierra Leone">Sierra Leone',
'<option value="SG,Singapore">Singapore',
'<option value="SK,Slovakia (Slovak Republic)">Slovakia (Slovak Republic)',
'<option value="SI,Slovenia">Slovenia',
'<option value="SB,Solomon Islands">Solomon Islands',
'<option value="SO,Somalia">Somalia',
'<option value="ZA,South Africa">South Africa',
'<option value="GS,South Georgia">South Georgia',
'<option value="ES,Spain">Spain',
'<option value="LK,Sri Lanka">Sri Lanka',
'<option value="VC,St Vincent And The Grenadines">St Vincent And The Grenadines',
'<option value="SH,St. Helena">St. Helena',
'<option value="PM,St. Pierre And Miquelon">St. Pierre And Miquelon',
'<option value="SD,Sudan">Sudan',
'<option value="SR,Suriname">Suriname',
'<option value="SJ,Svalbard And Jan Mayen Islands">Svalbard And Jan Mayen Islands',
'<option value="SZ,Swaziland">Swaziland',
'<option value="SE,Sweden">Sweden',
'<option value="CH,Switzerland">Switzerland',
'<option value="SY,Syrian Arab Republic">Syrian Arab Republic',
'<option value="TW,Taiwan">Taiwan',
'<option value="TJ,Tajikistan">Tajikistan',
'<option value="TZ,Tanzania">Tanzania',
'<option value="TH,Thailand">Thailand',
'<option value="TG,Togo">Togo',
'<option value="TK,Tokelau">Tokelau',
'<option value="TO,Tonga">Tonga',
'<option value="TT,Trinidad And Tobago">Trinidad And Tobago',
'<option value="TN,Tunisia">Tunisia',
'<option value="TR,Turkey">Turkey',
'<option value="TM,Turkmenistan">Turkmenistan',
'<option value="TC,Turks And Caicos Islands">Turks And Caicos Islands',
'<option value="TV,Tuvalu">Tuvalu',
'<option value="UG,Uganda">Uganda',
'<option value="UA,Ukraine">Ukraine',
'<option value="AE,United Arab Emirates">United Arab Emirates',
'<option value="GB,United Kingdom">United Kingdom',
'<option value="US,United States">United States',
'<option value="UY,Uruguay">Uruguay',
'<option value="UM,US Minor Outlying Islands">US Minor Outlying Islands',
'<option value="UZ,Uzbekistan">Uzbekistan',
'<option value="VU,Vanuatu">Vanuatu',
'<option value="VA,Vatican City State">Vatican City State',
'<option value="VE,Venezuela">Venezuela',
'<option value="VN,Viet Nam">Viet Nam',
'<option value="VG,Virgin Islands - British">Virgin Islands - British',
'<option value="VI,Virgin Islands - U.S.">Virgin Islands - U.S.',
'<option value="WF,Wallis And Futuna Islands">Wallis And Futuna Islands',
'<option value="EH,Western Sahara">Western Sahara',
'<option value="YE,Yemen">Yemen',
'<option value="YU,Yugoslavia">Yugoslavia',
'<option value="ZM,Zambia">Zambia',
'<option value="ZW,Zimbabwe">Zimbabwe',
'</select></td>',
'</tr>',
'</table>',
'<br>',
'<table>',
'<tr align="left">',
'<td>* Return Contact Preference:',
'<input type="radio" name="Contact_Preference" class="form-radio" value="E-mail">E-mail',
'<input type="radio" name="Contact_Preference" class="form-radio" value="Phone">Phone</td>',
'</tr>',
'</table>',
'<br>',
'Will you be a guest at The Carlton Tower during this time?<br>',
'<input type="hidden" name="guest_at_MJ">',
'<input type="radio" name="guest_at_MJ" value="Yes"> Yes  &nbsp; Please provide confirmation number: <input type="text" name="confirmation_number" class="form-text" size="15"><br>',
'<input type="radio" name="guest_at_MJ" value="No"> No<br>',
'<br>',
'Have you ever heard of The Peak Health Club before? If so, where?<br>',
'<input type="hidden" name="heard_SSS">',
'<input type="radio" name="heard_SSS" value="Yes"> Yes &nbsp; Where: <input type="text" name="heard_SSS_where" class="form-text" size="15"><br>',
'<input type="radio" name="heard_SSS" value="No"> No<br>',
'<br>',
'',
'<b>Additional comments or questions:</b><br>',
'<textarea name="Comments" rows="3" cols="40" wrap="virtual" class="form-textarea"></textarea>	  <br>',
'<div align="right"><input type="submit" name="submit" value="Submit request" class="form-button">&nbsp;</div>',
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'<table>',
'<tr>',
'<td>Note: * = required field</td>',
'</tr>',
'</table>',
'<table><tr>',
'<td><br>',
'<a href="mailto:stuart.brand@jumeirah.com?subject=I%20would%20like%20to%20modify%20or%20cancel%20a%20booking">Cancel or modify a booking</a><br><br>',
'<em>A cancellation made with less than 12 hours notice will result in a charge of 50% of the treatment cost. A cancellation made with less than 6 hours notice will result in the full cost of the treatment being charged.</em></td>',
'</tr></table>',
'</form>',
'<script language="javascript">',
'initDynamicOptionLists();',
'</script>',
'',
 

'');