document.write('<script type=\"text/javascript\" src=\"https://assets.bravenet.com/bn/js/emailfwd/bn_email_forms.min.js\"></script><link rel=\"stylesheet\" href=\"https://pub9.bravenet.com/emailfwd/v2/bnet-form.css.php?usernum=767813348&formid=4073&formpadding=0\"><form method=\"post\" class=\"bnet-form\" enctype=\"multipart/form-data\" action=\"#bn-ajax-post:767813348:9:4073\"><div class=\"bn-form-header\"><div class=\"bn-form-legend\"><div>Contact Us</div></div> <div class=\"bn-form-desc\"><p>Please fill out the fields below.</p></div></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">Name <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-1\" placeholder=\"your first and last name\" validator=\"\" value=\"\" required=\"required\"></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">Email Address <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-2\" placeholder=\"you must enter a valid email address\" validator=\"email\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper\"><label class=\"bn-row\"><span class=\"bn-label\">Phone Number </span> <span class=\"bn-input\"><input type=\"text\" name=\"\" placeholder=\"\" validator=\"\" value=\"\"></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">Please complete this box with your inquiry <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><textarea name=\"Field-3\" placeholder=\"enter your comments here\" validator=\"\" required=\"required\"></textarea></span></label></div>  <input type=\"hidden\" name=\"carboncopy\" value=\"\"> <input type=\"hidden\" name=\"thankyou\" value=\"http://www.handtherapy.ca/thanks.php\"> <input type=\"hidden\" name=\"thankyoutext\" value=\"\"> <input type=\"hidden\" name=\"subject\" value=\"New Web Contact\"><div class=\"bn-form-submit\"><button type=\"submit\" class=\"formbtn\">Submit Form</button></div> <style type=\"text/css\">.bnet-form ::-webkit-input-placeholder {');
document.write('  color:rgba(0,0,0,0.3)!important;');
document.write('}');
document.write('.bnet-form ::-moz-placeholder {');
document.write('  color:rgba(0,0,0,0.3)!important;');
document.write('}');
document.write('.bnet-form :-ms-input-placeholder {');
document.write('  color:rgba(0,0,0,0.3)!important;');
document.write('}');
document.write('.bnet-form :-moz-placeholder {');
document.write('  color:rgba(0,0,0,0.3)!important;');
document.write('}');
document.write('.bn-form-legend, .bn-form-legend div {');
document.write('      font-size:23px;');
document.write('      font-family:Arial, Helvetica, sans-serif;');
document.write('      color:#000000;');
document.write('}');
document.write('.bn-form-desc {');
document.write('	  font-size:15px;');
document.write('    font-family:Arial, Helvetica, sans-serif;');
document.write('    color:#222222;');
document.write('}');
document.write('#the-form, .bnet-form, .form-wrapper, .bn-form-preview, .bn-thankyou-msg {');
document.write('     background-color:#ffffff;');
document.write('}');
document.write('.bn-form-submit .formbtn {');
document.write('	 font-size:15px!important;');
document.write('      font-family:Arial, Helvetica, sans-serif!important;');
document.write('      color:#ffffff!important;');
document.write('      border-radius:7px!important;');
document.write('      background-color:#474747!important;');
document.write('}');
document.write('.bn-label {');
document.write('	font-size:15px;');
document.write('	font-family:Arial, Helvetica, sans-serif;');
document.write('	color:#000000!important;');
document.write('}');
document.write('.bn-thankyou-msg, .bn-form-preview {');
document.write('   font-family:Arial, Helvetica, sans-serif;');
document.write('	color:#000000;');
document.write('}');
document.write('.bn-response {');
document.write('  color:#000000;');
document.write('}');
document.write('.bn-input input[type=text], .bn-input textarea {');
document.write('	font-size:15px;');
document.write('	font-family:Arial, Helvetica, sans-serif;');
document.write('	color:#000000;');
document.write('	border-radius:5px;');
document.write('	border-color:#c4c4c4;');
document.write('	border-width:1px;');
document.write('	background-color:#ffffff;');
document.write('}');
document.write('.bn-select {');
document.write('	border-style:solid;display:inline-block;width:100%;overflow:hidden;box-sizing:borderbox;');
document.write('	border-color:#c4c4c4;');
document.write('	border-width:1px;');
document.write('	background-color:#ffffff;');
document.write('	border-radius:5px;');
document.write('}');
document.write('.bn-select select {');
document.write('  box-sizing:borderbox;');
document.write('	font-size:15px;');
document.write('	font-family:Arial, Helvetica, sans-serif;');
document.write('	color:#000000;');
document.write('	background-color:#ffffff;');
document.write('	border:0;');
document.write('}');
document.write('.bn-input label.bn-radio, .bn-input label.bn-checkbox {');
document.write('	font-size:15px;');
document.write('	font-family:Arial, Helvetica, sans-serif;');
document.write('	color:#000000!important;');
document.write('}');
document.write('.bn-radio input, .bn-checkbox input {');
document.write('	font-size:15px;');
document.write('	font-family:Arial, Helvetica, sans-serif;');
document.write('	color:#000000;');
document.write('	border-radius:5px;');
document.write('	border-color:#c4c4c4;');
document.write('	border-width:1px;');
document.write('	background-color:#ffffff;');
document.write('	display: none;');
document.write('}');
document.write('label.bn-checkbox, label.bn-radio {');
document.write('  position: relative;');
document.write('  padding-left: 36px;');
document.write('  line-height: 32px;');
document.write('}');
document.write('label.bn-checkbox span.bn-inner-label:before, label.bn-radio span.bn-inner-label:before,');
document.write('label.bn-checkbox span.bn-inner-label:after, label.bn-radio span.bn-inner-label:after {');
document.write('  font-family: \'Material Icons\';');
document.write('  text-rendering: optimizeLegibility;');
document.write('  font-feature-settings: \"liga\" 1;');
document.write('  font-style: normal;');
document.write('  text-transform: none;');
document.write('  line-height: 32px;');
document.write('  font-size: 32px;');
document.write('  width: 32px;');
document.write('  height: 32px;');
document.write('  text-align: center;');
document.write('  top: 0px;');
document.write('  left: 0px;');
document.write('  display: inline-block;');
document.write('  overflow: hidden;');
document.write('  -webkit-font-smoothing: antialiased;');
document.write('  -moz-osx-font-smoothing: grayscale;');
document.write('  transition: all .2s;');
document.write('  color: #ccc;');
document.write('  color:#cccccc;');
document.write('  position: absolute;');
document.write('}');
document.write('label.bn-radio span.bn-inner-label:before {');
document.write('  background: -moz-radial-gradient(center, ellipse cover,#ffffff 0px,#ffffff 9px,rgba(0,0,0,0) 14px,rgba(0,0,0,0) 100%);');
document.write('  background: -webkit-radial-gradient(center, ellipse cover, #ffffff 0px,#ffffff 9px,rgba(0,0,0,0) 14px,rgba(0,0,0,0) 100%);');
document.write('  background: radial-gradient(ellipse at center, #ffffff 0px,#ffffff 9px,rgba(0,0,0,0) 14px,rgba(0,0,0,0) 100%);');
document.write('}');
document.write('label.bn-checkbox span.bn-inner-label:before {');
document.write('  background: -moz-radial-gradient(left,rgba(255,255,255,0) 0px,rgba(255,255,255,0) 5px,#ffffff 5px,#ffffff 27px, rgba(0,0,0,0) 26px,rgba(0,0,0,0) 100%);');
document.write('  background: -webkit-radial-gradient(left, rgba(255,255,255,0) 0px,rgba(255,255,255,0) 5px,#ffffff 5px,#ffffff 27px, rgba(0,0,0,0) 26px,rgba(0,0,0,0) 100%);');
document.write('  background: linear-gradient(to right, rgba(255,255,255,0) 0px,rgba(255,255,255,0) 5px,#ffffff 5px,#ffffff 27px, rgba(0,0,0,0) 26px,rgba(0,0,0,0) 100%);');
document.write('  background-size: 28px 21px;');
document.write('  background-repeat: no-repeat;');
document.write('  background-position-y: 5px;');
document.write('}');
document.write('label.bn-checkbox span.bn-inner-label:before  {');
document.write('  content: \'check_box_outline_blank\';');
document.write('}');
document.write('label.bn-radio  span.bn-inner-label:before {');
document.write('  content: \'radio_button_unchecked\';');
document.write('}');
document.write('input[type=checkbox]:checked + span.bn-inner-label:before, input[type=radio]:checked + span.bn-inner-label:before {');
document.write('  opacity: 0;');
document.write('}');
document.write('input[type=checkbox] + span.bn-inner-label:after {');
document.write('  content: \'check_box\';');
document.write('  color:#2696f9;');
document.write('  color:#2696f9;');
document.write('}');
document.write('');
document.write('input[type=radio] + span.bn-inner-label:after {');
document.write('  content: \'radio_button_checked\';');
document.write('  color:#2696f9;');
document.write('  color:#2696f9;');
document.write('}');
document.write('input[type=radio]:not(:checked) + span.bn-inner-label:after,');
document.write('input[type=checkbox]:not(:checked) + span.bn-inner-label:after {');
document.write('  opacity: 0;');
document.write('  transform: scale(.3);');
document.write('}');
document.write('');
document.write('input[type=radio]:checked + span.bn-inner-label:after,');
document.write('input[type=checkbox]:checked + span.bn-inner-label:after {');
document.write('  opacity: 1;');
document.write('  transform: scale(1);');
document.write('}');
document.write('.bn-date-input {');
document.write('  position: relative;');
document.write('}');
document.write('.bn-date-input .bn-date-pick {');
document.write('  position: absolute;');
document.write('  width: 24px;');
document.write('  height: 24px;');
document.write('  font-size: 24px;');
document.write('  right: 5px;');
document.write('  top: 50%;');
document.write('  margin-top: -13px;');
document.write('');
document.write('}');
document.write('.bn-date-input .bn-date-pick {');
document.write('  color: #000;');
document.write('  color:#c4c4c4;');
document.write('  opacity: 0.75;');
document.write('}</style></form>');
document.write('<scr' + 'ipt src="//assets.bnidx.com/pixel/proMarket"></scr' + 'ipt>');