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     Code created by Medseek, Inc. 2028 Village Lane, Solvang CA 93463.
     Phone 1-888 MEDSEEK. email info@medseek.com. http://www.medseek.com 
     (c) 1999-2010 Medseek, Inc. All rights reserved.-->
    













	
	
	 
	 
	 
	 

	
	
	
	

	
	

	
	

	
	

	
	

	
	

	
	


	
	

	
	

	
	
	
	
	

	
	

	
	

	
	

	
	

	
		
		
	
		

	
		

	
		

	
		

	 
	 
	 
	 

	
	
	
	
	
	
	
	
		
	

	
	 
	
	
	
	
	
	

	
	
	
	
	

	
	

	
	

	
	

	
	

	
	

	
	

	
	

	
	

	
	

	
	

	
	

	
	
	
	
	
	
	
	
	
	

	
	

	
	

	
	
	
	
	

	
	

	
	

	
	

	
	

	
	

	
	

	
	

	
	

	
	
	
	

	
	

	
	
	
	
	

	
	

	
	

	
	

		
	
	
	
	
	
	
	
	
	
	

	
	

	
	

	

	
	

	
	

	
	

	
	

	
	

	
	
	
	
	

	
	

	
	

	
	

	
	

	
	

	
	

	
	

	
	

	
	

	
	

	
	

	
	

	
	

	
	

	
	
	
	
	

	
	

	
	

	
	

	
	

	
	

	
		
		
	
		

	
		

	
		

	
		
	
	
		
		
	
		
	
	
		
	
	
	
		
	
	
	
	
	
	
	
	

	
	
	
	
	
		
		
			

		
		
		
		
		
		
		
		
		
		
		
		
		
		

		
			
		
		 
		
		
		
		

		
		
		
		
		
		
		
		
		
		

		
		
		
		

		

		
		
		

			
				
			
		
		
		
		
		

		
		
		
		
		
		
		
			

		
		
		
		
				
		
		
		
				
		
			
		

		
		
		
		
		
		
	
		
			
			
			
		
		
		
	
		
			
			
		

		
		
		
		
			

		

		
		
		

			
				
			
		
		
		
		
		

		
		
		
		
		
		

		
					
						
		
		
				
		
		
		
		
		
				
		
		

		
		
		
		
		
		
		
		
			
			
				
			
		
		
		
		
		
			
			
		
		
		
		
		
			
			
		

		
		
		
			
			
		
		
		

		
			

			
		
		

		
		

		
				
		 
		
			
		
		
		

		
			
			
		
		
		
			

		

		
		
		
		

		
		

		
		
		
		
		
		
		
		
		
		

		
		

		
	
	
	
	




	
	
	

	
	
	
	
	
	
	
	
	
	

	
	


	
	
		
			
		
	
	
	
	
	
		
			
		
	
	
	
	
	

 


	
	
	
		



		
		
		
		
		
		
		
		
		
		
		
		
		
		
		
		
		
		
		
		

		
		

		
		
		
		

		

		
		
		

			
				
			
		
		
		
		
		

		
		
		
		
		
		
		
			

		
		
		
		
				
		
		
		
				
		
			
		

		
		
		
		
		
		
	
		
			
			
			
		
		
		
	
		
			
			
		

		
		
		
		
			

		

		
		
		

			
				
			
		
		
		
		
		

		
		
		
		
		
		

		
					
						
		
		
				
		
		
		
		
		
				
		
		

		
		
		
		
		
		
		
		
			
			
				
			
		
		
		
		
		
			
			
		
		
		
		
		
			
			
		

		
		
		
			
			
		
		
		

		
			

			
		
		

		
		

		
				
		 
		
			
		
		
		

		
			
			
			
		
		
			

		

		
		
		
	
		

		
		

		
		
		
		
			
		
		
		
			

		
		

		
		

		
		
		
		
		
		
		
		

		
		
		
		
			

		
		

		
		

		
		
		
		
		
		
		
			

		
		
		
		
		
		
		
		
		
		
		
		
		
		

		
			
		
		 
		
		
		
		

		
		
		
		
		
		
		
		
		
		

		
		
		
		

		

		
		
		

			
				
			
		
		
		
		
		

		
		
		
		
		
		
		
			

		
		
		
		
				
		
		
		
				
		
			
		

		
		
		
		
		
		
	
		
			
			
			
		
		
		
	
		
			
			
		

		
		
		
		
			

		

		
		
		

			
				
			
		
		
		
		
		

		
		
		
		
		
		

		
					
						
		
		
				
		
		
		
		
		
				
		
		

		
		
		
		
		
		
		
		
			
			
				
			
		
		
		
		
		
			
			
		
		
		
		
		
			
			
		

		
		
		
			
			
		
		
		

		
			

			
		
		

		
		

		
				
		 
		
			
		
		
		

		
			
			
		
		
		
			

		

		
		
		
		

		
		

		
		
		
		
		
		
		
		
		
		

		
		
		

		
		
		
		
		
		
			

		
		

		
		

		
		
		
		
		
		
		
			
				

		
		
		
		
		
		
		
		
		
		
		
		
		
		

		
			
		
		 
		
		
		
		

		
		
		
		
		
		
		
		
		
		

		
		
		
		

		

		
		
		

			
				
			
		
		
		
		
		

		
		
		
		
		
		
		
			

		
		
		
		
				
		
		
		
				
		
			
		

		
		
		
		
		
		
	
		
			
			
			
		
		
		
	
		
			
			
		

		
		
		
		
			

		

		
		
		

			
				
			
		
		
		
		
		

		
		
		
		
		
		

		
					
						
		
		
				
		
		
		
		
		
				
		
		

		
		
		
		
		
		
		
		
			
			
				
			
		
		
		
		
		
			
			
		
		
		
		
		
			
			
		

		
		
		
			
			
		
		
		

		
			

			
		
		

		
		

		
				
		 
		
			
		
		
		

		
			
			
		
		
		
			

		

		
		
		
		

		
		

		
		
		
		
		
		
		
		
		
		

		

		

		
		
		
		
		
		
		
		
		
		
		
		

		
			
		
		

		
		
		
		


		
			

		

		
		
		

	
		
		
		
		

		


	 
	 
	 
	 

	
	
	
	

	
	

	
	

	
	

	
	

	
	

	
	


	
	

	
	

	
	
	
	
	

	
	

	
	

	
	

	
	

	
		
		
	
		

	
		

	
		

	
		

	 
	 
	 
	 
	
	
	
	
	
	
	
	
	
	
	

	
	

	
	

	
	
	
	
	
	
	
	

	
	

	
	

	
	

	
	
	
	
	

	
	

	
	

	
	
	
	
	

	
	

	
	

	
	

	
	

	
	

	
	

	
	

	
	

	
	
	
	
	

	
	

	
	

	
	




 

		
	

	
	
		





















 

	

 
























	<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 3.2 Final//EN">
	<HTML>










	<HEAD>
<meta name="verify-v1" content="0L6Ij7p7XTIcx3b55IxiK3Ot9qYv4rMRM2yfOUPvhAE=" />
	<TITLE>Order Patient Education Materials</TITLE>
	<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1">
	<meta name="description" content="">
	<meta name="keywords" content="">
	<style type="text/css">
		@import url(default.css);
	</style>         <script type="text/javascript">
var gaJsHost = (("https:" == document.location.protocol) ? "https://ssl." : "http://www.");
document.write(unescape("%3Cscript src='" + gaJsHost + "google-analytics.com/ga.js' type='text/javascript'%3E%3C/script%3E"));
</script>
<script type="text/javascript">
try {
var pageTracker = _gat._getTracker("UA-6396952-1");
pageTracker._trackPageview();
} catch(err) {}</script>
     
		<style name="text/css" class="search">		
			td.search {background-color: transparent; background-image: URL(images/clear.gif); font-family: verdana,arial; font-weight: 700; font-size: 12px; font-color: 000000;}
					
		</style>
	
<script language="javascript" type="text/javascript">
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	smt_fontsizeAddEvent(window, 'load', smt_fontsizeInit);
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		 // Set the font to the last saved value (in the cookie.)
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				smt_fontsizeIncrement(smt_fontsizeGetCookie(),true);
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				smt_fontsizeIncrement('0',true);
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			if(smt_fontsizeGetCookie() == 8){
				smt_fontsizeBtnStatus('increase','increase_.gif');
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		var curCookie = name + "=" + escape(value);
		
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	// function to get the cookie value.
	function smt_fontsizeGetCookie(){
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		if (document.cookie.indexOf(name) != -1) {
			cs=document.cookie.indexOf(name+"=");
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				ce=document.cookie.indexOf(";",cs);
				if(ce==-1) ce=document.cookie.length
				return parseInt(unescape(document.cookie.substring(cs,ce)));
			} else {
				return "";
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		} else {
			return "";
		} 
	}
	// A function to compute the current font size as rendered by the browser.
	function smt_fontsizeGetCurrentFontSize(elem){
		var ieFontScale	=	new Array ("10","11","12","14","18","24","30","36","48","60","72");
		if ( elem == null )
			return null;
		
		// if the style isn't defined inline, then ask the browser to compute the current size	
		if ( elem.style.fontSize == "")
		{
			var browserName=navigator.appName; 
			var browserVer=parseInt(navigator.appVersion); 
			if (browserName=="Microsoft Internet Explorer" && browserVer>=4) 
				//font element was deprecated in HTML 4.01
				//IE does not handle the increments well without this
				if(elem.tagName == "FONT"){
					var ieFontIndex = elem.getAttribute("size");
					if(ieFontIndex == "" || ieFontIndex < 0){
						return '12';
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						return ieFontScale[ieFontIndex];
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				} else {
					return elem.currentStyle.fontSize;
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			else
				if(navigator.vendor.indexOf('Apple') != 0){
					return document.defaultView.getComputedStyle(elem, '').getPropertyValue("font-size");
				} else {
					return '12';
				}
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		// else return the current fontsize.
		else
		{
			return elem.style.fontSize;
		} 
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	// Checks if an element is a child of a filtered node (one that should be resized.)
	function smt_fontsizeParentIsFiltered(elem_temp){
		var elem = elem_temp;
		var classname;
		while ( elem.parentNode != null && elem.parentNode.tagName != "HTML")
		{
			elem = elem.parentNode;
			try
			{
				if ( elem.getAttribute('class') != null )
					classname = elem.getAttribute('class');
				else
					classname = elem.className;
			
				var isResizable = classname.indexOf('content') >= 0;
			
				if (classname == "content" | isResizable)
					return true;
			} catch(err) {/*alert(elem + ": " + err.description + " ");*/}
		}
	
		return false;
	}
	// Increments the fontsize of an element.
	function smt_fontsizeIncrementElement(elem,size){
		var currentSize;
		var currentVal;
		var currentUnit;
		var unitPattern = /[A-Z]+$/i;
		
		
		if ( smt_fontsizeParentIsFiltered(elem) )
		{
		
			currentSize = smt_fontsizeGetCurrentFontSize(elem);
			currentVal = currentSize.substring(0,currentSize.search(unitPattern));
			currentUnit = currentSize.substring(currentSize.search(unitPattern),currentSize.length);

			if ( size + parseFloat(currentVal) > 0)
				elem.style.fontSize = (size + parseFloat(currentVal)) + currentUnit;
		
		}
		
	}
	// Increments the font size of every element on the page by "size."
	// Size can be either +,-,default, or an integer value between the max and min allowed.
	// the dontUpdateCookie flag prevents the function from updating the cookie after the font resize.
	function smt_fontsizeIncrement(size,dontUpdateCookie){
		if( size == "+" )
			size = 2;	
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			size = -2;
		else if ( size == "default" ){
			size = -smt_fontsizeGetCookie();
			
				smt_fontsizeBtnStatus('increase','increase.gif');
				smt_fontsizeBtnStatus('decrease','decrease.gif');
			
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		if ( dontUpdateCookie == null )
			smt_fontsizeSetCookie( size + smt_fontsizeGetCookie() );
			
		for ( var i=0; element = document.getElementsByTagName("*")[i]; i++ )
			smt_fontsizeIncrementElement(element,size);
		
		
			if(smt_fontsizeGetCookie() <= -2){
				smt_fontsizeBtnStatus('decrease','decrease_.gif');
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<script type="text/javascript">
//<!--
var ns4 = (document.layers);
var ie  = (document.all);
var ie4 = (ie && !document.getElementById);
var ie5 = (ie && document.getElementById);
var ns6 = (!ie && document.getElementById);

var aryMoused = new Array();
var aryLayerMoused = new Array();
var aryMoImages = new Array();
var imageList = new Array();
var runMouseOvers = true;
var TimerID = null;
var iLimit = 25;
var itmp = 0;

var nbTime = 100;
var nbTimes = 2;
var nbThisLoc = 325;
var aryLayerNames = new Array();
var aryNavBarLayerInfo = new Array();
var aryNavBarLayers = new Array();

var registeredObjects = new Array();
var viz = "hide";

function MOImage() {
	var arg = MOImage.arguments;
	this.ptrImage = BillzNavBarMM_findObj(arg[0]);
	this.imageMO = new Image();
	this.imageMO.src = arg[1];
	this.HTMLname = arg[0];
	this.Moused = false;
	this.OriginalSrc = '';
	return true;
}

function BillzImagePreload() {
	// 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]);
}

function nbImagePreload(img_name, mo_img_src, rollover_key_img_name) {
	var imageKey = (rollover_key_img_name.length > 0) ? rollover_key_img_name : img_name;
	imageList[imageList.length] = imageKey;
	if (!(aryMoImages[imageKey])) aryMoImages[imageKey] = new MOImage(img_name, mo_img_src);
}

function BillzMouseover() {
	var arg = null;
	if (runMouseOvers) {		
		arg = BillzMouseover.arguments; //args 0)ImageName 1)OriginalSrc 2)array index (caller imagename)		
		nbMouseover(arg[0], arg[1], arg[2]);
	}
	return true;
}
// args 1) ImageName 2) OriginalSrc 3) array index (caller imagename)
function nbMouseover(img_name, orig_src, img_key) {
	var imageKey = null;
	var o = null;
	if (runMouseOvers) 
	{				
		imageKey = (img_key.length > 0) ? img_key : img_name;
		if (!(aryMoImages[imageKey].ptrImage)) aryMoImages[imageKey].ptrImage = BillzNavBarMM_findObj(img_name);		
		if (aryMoImages[imageKey] && (o = aryMoImages[imageKey].ptrImage)) {
			aryMoImages[imageKey].OriginalSrc = orig_src;
			aryMoImages[imageKey].Moused = true;
			o.src = aryMoImages[imageKey].imageMO.src;
		}
	}
	return true;
}

var NavBarTempOnload = null;
if (window.onload && window.onload != null) NavBarTempOnload = window.onload;

function FullyLoaded() {
	if (NavBarTempOnload != null) NavBarTempOnload();
	runMouseOvers = true;
	return true;
}

function BillzMouseOutTimer() {
	return nbMouseOutTimer();
}

function nbMouseOutTimer() {
	if (TimerID) clearTimeout(TimerID);
	TimerID = setTimeout("nbLayerRestore()",5000);
	return true;
}

function RestoreAll() {
	nbMouseoverRestore();
	nbLayerRestore();
	return true;
}

function BillzMouseoverRestore() {
	return nbMouseoverRestore();
}

function nbMouseoverRestore() {
	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)) {
				o.src = aryMoImages[imageList[i]].OriginalSrc;
				aryMoImages[imageList[i]].Moused = false;
			}
		}
	}
	return true;
}

function BillzLayerRestore() {
	return nbLayerRestore();
}

function nbLayerRestore() {
	var i = 0;
	for (i = 0; i < aryLayerNames.length; i++) {
		if (!aryNavBarLayerInfo[aryLayerNames[i]].isDefault) BillzNavBarRestoreLayers(aryLayerNames[i]);	
	}
	return true;
}

function BillzArrayPushUnique(aryArray, varNewElement) { //only pushes if unique value
	var pushIt = true;
	var i = 0;
	for (i = 0; i < aryArray.length && pushIt; i++) {
		pushIt = (varNewElement != aryArray[i]);
	}
	if (pushIt) BillzArrayPush(aryArray, varNewElement);
	return pushIt;
}

function BillzArrayPush(aryArray, varNewElement) { //Implement Array Push 'cause IE cant handle it
	aryArray[aryArray.length] = varNewElement;
	return true;
}
function BillzArrayPop(aryArray) { //Implement Array Pop 'cause IE cant handle it before 5.5
	var varItemToPop = null;
	if (aryArray[aryArray.length - 1]) {
		varItemToPop = aryArray[aryArray.length - 1];
		aryArray[aryArray.length] = null;
	}
	return varItemToPop;
}

function getDivRef(id) {
	var divref;
	if(ns4) divref = document.layers[id];
	else if(ie4) divref = document.all[id];
	else if(ie5 || ns6) divref = document.getElementById(id);	
	return divref;
}

//v3.0 name changed to avoid clash with possible other JS in content, this function complements of MM Dreamweaver
function NavBarSwapRollover(swapimage,defaultimage,imageID) {
	if(imageID.length > 0 && document.getElementById(imageID))
	{
		if(swapimage.length > 0) 
			document.getElementById(imageID).src = "images/" + swapimage;
		else
			document.getElementById(imageID).src = "images/" + defaultimage;		
	}
}
function BillzNavBarMM_findObj(n, d) {
	var p,i,x;
	if (ns6) x = document.getElementById(n);
	else {		
		if (registeredObjects[n]) return registeredObjects[n];
		if (!(d)) d = document;
		try {
			p = n.indexOf("?");
		}
		catch(e) {
			p = 0;
		}
		if (p > 0 && parent.frames.length) {
			d = parent.frames[n.substring(p+1)].document;
			n = n.substring(0,p);
		}
		if (!(x = d[n]) && d.all) x = d.all[n];	
		for (i = 0; !x && i < d.forms.length; i++) {
			x = d.forms[i][n];
		}
		for (i=0; !x && d.layers && i < d.layers.length; i++) {
			if (d.layers[i].id.indexOf("external_") == -1) x = BillzNavBarMM_findObj(n, d.layers[i].document);	
		}
		registeredObjects[n] = x;
	}				
	return x;
}

function BillzArrayContains() {
	var arg = BillzArrayContains.arguments;
	var foundit = false;
	var i = 0;
	for (i = 0; i < arg[0].length && !foundit; i++) {
		foundit = (arg[1] == arg[0][i]);
	}
	return foundit;
}

function NavBarRegisterLayer() {
	var arg = NavBarRegisterLayer.arguments;
	var n = arg[0];
	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();
	for (i = 0; i < (args.length - 2); i += 3) {
		if (!aryNavBarLayers[args[i]]) {
			x = (args[i + 2] == 'show') ? 'hide' : 'show';
			NavBarRegisterLayer(args[i], x);
		}
		if ((obj = aryNavBarLayers[args[i]]) != null) {
			v = args[i + 2];
			aryNavBarLayerInfo[args[i]].isDefault = false;
			if (args[args.length - 1] == "restore") v = (v == 'show') ? 'hide' : 'show';
			
			if (obj.style) obj.style.visibility = (v == 'show') ? 'visible' : ((v == 'hide') ? 'hidden' : v);
			else obj.visibility = v;
		}
	}
	return true;
}

function BillzNavBarRestoreLayers() {
	var i = 0;
	var x = "";
	var obj = null;
	var v = null;
	var p = null;
	var args = BillzNavBarRestoreLayers.arguments;
	for (i = 0; i < (args.length); i++) {
		if (obj = aryNavBarLayers[args[i]]) {
			v = aryNavBarLayerInfo[args[i]].defaultVisibility;
			if (obj.style) {
				obj = obj.style;
				v = (v == 'show' ) ? 'visible' : ((v == 'hide') ? 'hidden' : v);
			}
			obj.visibility = v;
			if (!aryNavBarLayerInfo[args[i]].MOutLayer) aryNavBarLayerInfo[args[i]].isDefault = true;			
		}
	}
	return true;
}

function NavBarLayer() {
	var arg = NavBarLayer.arguments;
	this.defaultVisibility = arg[1];
	this.isDefault = true;
	this.MOutLayer = arg[2];
	return true;
}

function BillzNavMove() {
	return nbNavMove();
}

function nbNavMove() {
	var thisl = null;
	var otherl = null;
	if (thisl = BillzNavBarMM_findObj("nbScrollLayer")) {
		if (thisl.style) {
			thisl = thisl.style;
			viz = "hidden";
		} 
		thisl.top = nbThisLoc -= 3;
		if (nbThisLoc < -750) {
			nbThisLoc = 325;
			nbTimes--;
		}
	}
	if (nbTimes <= 0) {
		otherl = BillzNavBarMM_findObj("BillzLayer");
		otherl.visibility = viz;
	} else {
		setTimeout("nbNavMove()", nbTime);
	}	
	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;
//-->
</script>
					
<script type="text/javascript">
//<!--
function NavBar_setCookie(cookievalue,navVersion,linkID) 
{	
	var cookiename = "SLIDINGTABLE_NAVBAR" + navVersion;
	var cookieVersionname = "SLIDINGTBL_NAVBAR_VERSION";
	var cookieClear = "SLIDINGTBL_NAVBAR_CLEARCOOKIES";	
	document.cookie = cookieClear.toUpperCase() + "=false";
	if(cookievalue.length > 0)
		document.cookie = cookiename.toUpperCase() + "=" + escape(cookievalue);
	if(navVersion.length > 0)	
		document.cookie = cookieVersionname.toUpperCase() + "=" + navVersion;	
	if(linkID.length > 0)
		NavBar_setPLinkIDCookie(linkID,navVersion);		
}
function NavBar_setoLevelIDCookie(cookievalue,linkID,navVersion) 
{
	var name = "SLIDINGTBL_NAVBAR_OLEVELID";		
	if(cookievalue.length > 0)
		document.cookie = name.toUpperCase() + "=" + escape(cookievalue);	
	if(linkID.length > 0)
		NavBar_setPLinkIDCookie(linkID,navVersion);	
	if(navVersion.length > 0)	
		document.cookie = "SLIDINGTBL_NAVBAR_VERSION=" + navVersion;		
}
function NavBar_setPLinkIDCookie(linkID,navVersion)
{	
	document.cookie = "SLIDINGTBL_NAVBAR_PLINKID=" + linkID;	
	if(navVersion.length > 0)	
		document.cookie = "SLIDINGTBL_NAVBAR_VERSION=" + navVersion;
}
function NavBar_deleteCookie() 
{
	// first we'll split this cookie up into name/value pairs
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                        <td width="50%" valign="top" class="date" align="right" style="padding: 7px 0px 0px 0px;"><img src="images/brmc/tagline.gif"><br>Wed, September 08, 2010 &nbsp; &nbsp;<br><br></td>
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	</tr>
	<tr class="metadetail">
		<th valign="top" class="metadetail">Cardiac Catheterization&nbsp;</th>
		<td class="metadetail">
			<input type="Text" name="eformField_3" class="metadetail" size="35" value="">
		</td>
	</tr>
	<tr class="metadetail">
		<th valign="top" class="metadetail">Cardiac Treadmill Test&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">Computerized Tomography CT Scan&nbsp;</th>
		<td class="metadetail">
			<input type="Text" name="eformField_5" class="metadetail" size="35" value="">
		</td>
	</tr>
	<tr class="metadetail">
		<th valign="top" class="metadetail">EEG (Electroencephalogram)&nbsp;</th>
		<td class="metadetail">
			<input type="Text" name="eformField_6" class="metadetail" size="35" value="">
		</td>
	</tr>
	<tr class="metadetail">
		<th valign="top" class="metadetail">Evoked Potential Studies&nbsp;</th>
		<td class="metadetail">
			<input type="Text" name="eformField_7" class="metadetail" size="35" value="">
		</td>
	</tr>
	<tr class="metadetail">
		<th valign="top" class="metadetail">Esophagram (Barium Swallow) Upper GI Small Bowel&nbsp;</th>
		<td class="metadetail">
			<input type="Text" name="eformField_8" class="metadetail" size="35" value="">
		</td>
	</tr>
	<tr class="metadetail">
		<th valign="top" class="metadetail">Gallbladder and Abdominal Ultrasound&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">Holter Monitor&nbsp;</th>
		<td class="metadetail">
			<input type="Text" name="eformField_10" class="metadetail" size="35" value="">
		</td>
	</tr>
	<tr class="metadetail">
		<th valign="top" class="metadetail">Intravenous Pyelogram (IVP or Urogram)&nbsp;</th>
		<td class="metadetail">
			<input type="Text" name="eformField_11" class="metadetail" size="35" value="">
		</td>
	</tr>
	<tr class="metadetail">
		<th valign="top" class="metadetail">Lower GI (Barium Enema)&nbsp;</th>
		<td class="metadetail">
			<input type="Text" name="eformField_12" class="metadetail" size="35" value="">
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	<tr class="metadetail">
		<th valign="top" class="metadetail">Magnetic Resonance Imaging (MRI)&nbsp;</th>
		<td class="metadetail">
			<input type="Text" name="eformField_13" class="metadetail" size="35" value="">
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		<th valign="top" class="metadetail">Myelogram&nbsp;</th>
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			<input type="Text" name="eformField_14" class="metadetail" size="35" value="">
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		<th valign="top" class="metadetail">Nuclear Medicine Myocardial Stress&nbsp;</th>
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			<input type="Text" name="eformField_15" class="metadetail" size="35" value="">
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		<th valign="top" class="metadetail">Obstetrical and Pelvic Ultrasound&nbsp;</th>
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		<th valign="top" class="metadetail">Prostatic Ultrasound Exam&nbsp;</th>
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		<th valign="top" class="metadetail">T.E.E.&nbsp;</th>
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		<th valign="top" class="metadetail">Thyroid Uptake and Scan&nbsp;</th>
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		<th valign="top" class="metadetail">Tilt Table Test&nbsp;</th>
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		<th valign="top" class="metadetail">Urodynamics Test&nbsp;</th>
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		<th valign="top" class="metadetail">Other Brochures&nbsp;</th>
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		<th valign="top" class="metadetail">Bariatric Surgery Program&nbsp;</th>
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		<th valign="top" class="metadetail">Visiting Nurse Services of Michigan - Medical Supplies&nbsp;</th>
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		<th valign="top" class="metadetail">Bay Special Care Hospital&nbsp;</th>
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		<th valign="top" class="metadetail">Cardiac Rehabilitation&nbsp;</th>
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		<th valign="top" class="metadetail">Outpatient Rehabilitative Services&nbsp;</th>
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		<th valign="top" class="metadetail">Osteoporosis&nbsp;</th>
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		<th valign="top" class="metadetail">Stereotactic Breast Biopsy&nbsp;</th>
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		<th valign="top" class="metadetail">Womens Services&nbsp;</th>
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			<input type="Text" name="eformField_30" class="metadetail" size="35" value="">
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		<th valign="top" class="metadetail">Important Contact Numbers Card&nbsp;</th>
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		<th valign="top" class="metadetail">Hospital Locations Map&nbsp;</th>
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			<input type="Text" name="eformField_32" class="metadetail" size="35" value="">
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		<th valign="top" class="metadetail">BRMC Site/Service Address and Phone Listing&nbsp;</th>
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		<th valign="top" class="metadetail">Deliver to:  Name&nbsp;<span class="required">*</span>&nbsp;</th>
		<td class="metadetail">
			<input type="Text" name="eformField_34" class="metadetail" size="35" value="">
			<input type="Hidden" name="eformField_34_required" class="metadetail" value="Deliver to:  Name is required.">
		</td>
	</tr>
	<tr class="metadetail">
		<th valign="top" class="metadetail">Office Name&nbsp;</th>
		<td class="metadetail">
			<input type="Text" name="eformField_35" class="metadetail" size="35" value="">
		</td>
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		<th valign="top" class="metadetail">Address&nbsp;<span class="required">*</span>&nbsp;</th>
		<td class="metadetail">
			<input type="Text" name="eformField_36" class="metadetail" size="35" value="">
			<input type="Hidden" name="eformField_36_required" class="metadetail" value="Address is required.">
		</td>
	</tr>
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		<th valign="top" class="metadetail">City/State/Zip&nbsp;<span class="required">*</span>&nbsp;</th>
		<td class="metadetail">
			<input type="Text" name="eformField_37" class="metadetail" size="35" value="">
			<input type="Hidden" name="eformField_37_required" class="metadetail" value="City/State/Zip is required.">
		</td>
	</tr>
	<tr class="metadetail">
		<th valign="top" class="metadetail">Phone Number&nbsp;<span class="required">*</span>&nbsp;</th>
		<td class="metadetail">
			<input type="Text" name="eformField_38" class="metadetail" size="35" value="">
			<input type="Hidden" name="eformField_38_required" class="metadetail" value="Phone Number is required.">
		</td>
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		<th valign="top" class="metadetail">Contact Person&nbsp;</th>
		<td class="metadetail">
			<input type="Text" name="eformField_39" class="metadetail" size="35" value="">
		</td>
	</tr>
	<tr class="metadetail">
		<th valign="top" class="metadetail">Email Address&nbsp;</th>
		<td class="metadetail">
			<input type="Text" name="eformField_40" class="metadetail" size="35" value="">
			<input type="Hidden" name="eformField_40_email" class="metadetail" value="Email Address must be a valid email address.">
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