<div style="margin: 12px 0px; font-family: arial; color: #333333; background: #ffffff; border: solid 4px #e5e5e5; width: 100%; clear: left;"><div class="CM_CTB_Content_Wrap" style="margin: 0px; padding: 0px;background-color: #ffffff;"><div style="border-bottom: solid 1px #dcdcdc; white-space: nowrap; margin-bottom: 8px; background-color: #eeeeee ;background-image: url(http://clipmarks.com/images/source-bg.gif); background-repeat: repeat-x; height: 24px; line-height: 24px; vertical-align: middle; padding-bottom: 4px; color: #666666; font-size: 10px;" ><a href="http://clipmarks.com/clip-to-blog/" title="see clips that are hot right now"><img src="http://content.clipmarks.com/blog_embed/ee46343e-3357-4a4a-b654-b2bcb7c90aa1/09A27A85-D73C-4867-92DC-6BF9ACCBF6B3/" alt="" width="19" height="19" border="0" style="vertical-align: middle; margin: 0px 4px; display: inline; border: none; float:none;" /></a>clipped from <a title="http://www.twinject.ca/mytwinject.edit.php?lang=en" href="http://www.twinject.ca/mytwinject.edit.php?lang=en" style="font-size: 11px;">www.twinject.ca</a></div><blockquote style="text-align: left; padding: 0px 8px; margin: 4px 0px 8px 0px; background: transparent; border: none;" cite="http://www.twinject.ca/mytwinject.edit.php?lang=en"><table background="undefined" bgcolor=""><tr><TD width="294" class="title">Personnal information</TD></tr></table></blockquote><div style="height: 2px; font-size: 2px; background: #dcdcdc; border-bottom: solid 1px #f5f5f5; margin: 2px 4px;"></div><blockquote style="text-align: left; padding: 0px 8px; margin: 4px 0px 8px 0px; background: transparent; border: none;" cite="http://www.twinject.ca/mytwinject.edit.php?lang=en"><table background="undefined" bgcolor=""><tr><TD valign="top"><TABLE cellspacing="0" cellpadding="0" border="0" id="left_column"><TBODY><TR><TD width="80">Type of user *</TD><TD width="183"><DIV id="select_type" tempfunction="" class="select_custom"><INPUT type="hidden" id="type" name="type" value="1" /><DIV class="select_top" id="type_top"><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self"type_dropped");">Patient</A></DIV><DIV class="select" id="type_dropped"><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">- Choose</A><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">Doctor</A><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">Nurse</A><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">Parent</A><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">Patient</A><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">Pharmacist</A><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">Teacher</A></DIV></DIV> </TD></TR><TR><TD>First name *</TD><TD><INPUT type="text" class="field" value="jasmine" name="firstname" id="firstname" /> </TD></TR><TR><TD>Last name *</TD><TD><INPUT type="text" class="field" value="williams" name="lastname" id="lastname" /> </TD></TR><TR><TD>Birthdate</TD><TD><INPUT type="text" class="field" name="day" value="11" id="day" maxlength="4" /> <DIV id="select_month" tempfunction="" class="select_custom"><INPUT type="hidden" id="month" name="month" value="6" /><DIV class="select_top" id="month_top"><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self"month_dropped");">Jun.</A></DIV><DIV class="select" id="month_dropped"><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">Month</A><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">Jan.</A><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">Feb.</A><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">Mar.</A><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">Apr.</A><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">May</A><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">Jun.</A><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">Jul.</A><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">Aug.</A><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">Sept.</A><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">Oct.</A><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">Nov.</A><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">Dec.</A></DIV></DIV> <INPUT type="text" class="field" value="2004" name="year" id="year" /> </TD></TR><TR><TD>Gender *</TD><TD><DIV id="select_gender" tempfunction="" class="select_custom"><INPUT type="hidden" id="gender" name="gender" value="f" /><DIV class="select_top" id="gender_top"><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self"gender_dropped");">Female</A></DIV><DIV class="select" id="gender_dropped"><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">Male</A><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">Female</A></DIV></DIV> </TD></TR><TR><TD>Address</TD><TD><INPUT type="text" class="field" value="5401 a 52nd avenue" name="address" id="address" /> </TD></TR><TR><TD>City *</TD><TD><INPUT type="text" class="field" value="bonnyville" name="city" id="city" /> </TD></TR><TR><TD>Province</TD><TD><DIV id="select_province" tempfunction="" class="select_custom"><INPUT type="hidden" id="province" name="province" value="1" /><DIV class="select_top" id="province_top"><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self"province_dropped");">Alberta</A></DIV><DIV class="select" id="province_dropped"><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">- Choose your province</A><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">Alberta</A><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">British Columbia</A><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">Manitoba</A><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">New Brunswick</A><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">Newfoundland</A><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">Northwest Territories</A><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">Nova Scotia</A><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">Ontario</A><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">Prince Edward Island</A><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">Quebec</A><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">Saskatchewan</A><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">Yukon</A><A href="javascript:alert('This link contains javascript. Please visit the clip source to follow this link.');" target="_self">Nunavut</A></DIV></DIV> </TD></TR><TR><TD>Country</TD><TD><SPAN class="country">Canada</SPAN></TD></TR><TR><TD>Postal code *</TD><TD><INPUT type="text" class="field" value="t9n2a3" name="postal_code" id="postal_code" /> </TD></TR><TR><TD width="103">Email address *</TD><TD width="183"><INPUT type="text" class="field" value="getmemoose@hotmail.com" name="emailaddress" id="emailaddress" /> </TD></TR><TR><TD>Telephone *</TD><TD><INPUT type="text" value="780" class="field" maxlength="3" id="inputphone_1" name="phone[]" /><INPUT type="text" value="815-6030" class="field" id="inputphone_2" name="phone[]" /> </TD></TR><TR><TD>Fax</TD><TD><INPUT type="text" value="" class="field" maxlength="3" id="inputfax_1" name="fax[]" /><INPUT type="text" value="" class="field" id="inputfax_2" name="fax[]" /> </TD></TR></TBODY></TABLE></TD></tr></table></blockquote><div style="height: 2px; font-size: 2px; background: #dcdcdc; border-bottom: solid 1px #f5f5f5; margin: 2px 4px;"></div><blockquote style="text-align: left; padding: 0px 8px; margin: 4px 0px 8px 0px; background: transparent; border: none;" cite="http://www.twinject.ca/mytwinject.edit.php?lang=en"><table background="undefined" bgcolor=""><tr><TD>Type of allergy *</TD></tr></table></blockquote><div style="height: 2px; font-size: 2px; background: #dcdcdc; border-bottom: solid 1px #f5f5f5; margin: 2px 4px;"></div><blockquote style="text-align: left; padding: 0px 8px; margin: 4px 0px 8px 0px; background: transparent; border: none;" cite="http://www.twinject.ca/mytwinject.edit.php?lang=en"><table background="undefined" bgcolor=""><tr><TD><DIV class="checkbox"><INPUT type="hidden" value="1" name="peanuts" id="peanuts" /><IMG src="http://www.twinject.ca/images/form_check_on.gif" id="peanuts_pic" /></DIV> <DIV class="tag">Peanuts</DIV> <DIV class="checkbox"><INPUT type="hidden" value="" name="tree_nuts" id="tree_nuts" /><IMG src="http://www.twinject.ca/images/form_check_off.gif" id="tree_nuts_pic" /></DIV> <DIV class="tag">Tree nuts</DIV> <DIV class="checkbox"><INPUT type="hidden" value="" name="shellfish" id="shellfish" /><IMG src="http://www.twinject.ca/images/form_check_off.gif" id="shellfish_pic" /></DIV> <DIV class="tag">Shellfish</DIV> <DIV class="checkbox"><INPUT type="hidden" value="" name="fish" id="fish" /><IMG src="http://www.twinject.ca/images/form_check_off.gif" id="fish_pic" /></DIV> <DIV class="tag">Fish</DIV> <DIV class="checkbox"><INPUT type="hidden" value="" name="milk" id="milk" /><IMG src="http://www.twinject.ca/images/form_check_off.gif" id="milk_pic" /></DIV> <DIV class="tag">Milk</DIV></TD></tr></table></blockquote><div style="height: 2px; font-size: 2px; background: #dcdcdc; border-bottom: solid 1px #f5f5f5; margin: 2px 4px;"></div><blockquote style="text-align: left; padding: 0px 8px; margin: 4px 0px 8px 0px; background: transparent; border: none;" cite="http://www.twinject.ca/mytwinject.edit.php?lang=en"><table background="undefined" bgcolor=""><tr><TD><DIV class="checkbox"><INPUT type="hidden" value="" name="eggs" id="eggs" /><IMG src="http://www.twinject.ca/images/form_check_off.gif" id="eggs_pic" /></DIV> <DIV class="tag">Eggs</DIV> <DIV class="checkbox"><INPUT type="hidden" value="" name="stings" id="stings" /><IMG src="http://www.twinject.ca/images/form_check_off.gif" id="stings_pic" /></DIV> <DIV class="tag">Insects stings</DIV> <DIV class="checkbox"><INPUT type="hidden" value="" name="latex" id="latex" /><IMG src="http://www.twinject.ca/images/form_check_off.gif" id="latex_pic" /></DIV> <DIV class="tag">Latex</DIV> <DIV class="checkbox"><INPUT type="hidden" value="" name="medication" id="medication" /><IMG src="http://www.twinject.ca/images/form_check_off.gif" id="medication_pic" /></DIV> <DIV class="tag">Medication</DIV></TD></tr></table></blockquote></div><div style="margin: 0px 6px 6px 4px;"><table style="font-size: 11px;border-spacing: 0px;padding: 0px;" cellpadding="0" cellspacing="0" width="100%"><tr><td style="background:transparent;border-width:0px;padding:0px;">&nbsp;</td><td align="right" style="background:transparent;border-width:0px;padding:0px;width:107px" width="107"><a href="http://clipmarks.com/share/09A27A85-D73C-4867-92DC-6BF9ACCBF6B3/blog/" title="blog or email this clip"><img src="http://content6.clipmarks.com/images/c2b-foot.png" border="0" alt="blog it" width="107" height="17" style="border-width:0px;padding:0px;margin:0px;" /></a></td></tr></table></div></div>

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