document.write('');
document.write('  <table align="center">');
document.write('<form method="post" action="http://90321.formmailer.onetwomax.de/">');
document.write('    <tr>');
document.write('      <td align="center" valign="middle" colspan="2"><font color="#000000" face="Arial" size="3"><b>Kontaktformular für Pelikan-Apotheke / Augsburg</b></font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td align="center" valign="middle" colspan="2"><font color="#FF0000" face="Arial" size="1"><b>mit * gekennzeichnete Felder müssen ausgefüllt werden</b></font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>&nbsp;</td>');
document.write('      <td></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#000000" face="Arial" size="2">Vorname, Name *</font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id3]" value="" size="40">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#000000" face="Arial" size="2">Wohnort *</font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id10]" value="" size="40">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#000000" face="Arial" size="2">E-Mail *</font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id4]" value="" size="40">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>&nbsp;</td>');
document.write('      <td></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#000000" face="Arial" size="2">Betreff *</font></td>');
document.write('      <td>');
document.write('        <select name="user_input[id8]">');
document.write('          <option value="0">...bitte auswählen');
document.write('</option>');
document.write('          <option value="1">- Allgemeine Anfrage');
document.write('</option>');
document.write('          <option value="2">- Beratung');
document.write('</option>');
document.write('          <option value="3">- Bestellung, bzw. Vorbestellung');
document.write('</option>');
document.write('          <option value="4">- Blutdruckmessung');
document.write('</option>');
document.write('          <option value="5">- Blutzuckermessung');
document.write('</option>');
document.write('          <option value="6">- Diabetes');
document.write('</option>');
document.write('          <option value="7">- Inkontinenzberatung');
document.write('</option>');
document.write('          <option value="8">- Kosmetische Pflegeprodukte');
document.write('</option>');
document.write('          <option value="9">- Kundenkarte');
document.write('</option>');
document.write('          <option value="10">- Auskunft über Medikament');
document.write('</option>');
document.write('          <option value="11">- Verleih von Baby-Waage');
document.write('</option>');
document.write('          <option value="12">- Reise-Impfberatung');
document.write('</option>');
document.write('          <option value="13">- Sonstiges');
document.write('</option>');
document.write('          <option value="14">');
document.write('</option>');
document.write('          <option value="15"></option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>&nbsp;</td>');
document.write('      <td></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#000000" face="Arial" size="2">Nachricht *</font></td>');
document.write('      <td>');
document.write('        <textarea name="user_input[id6]" style="width:100%" rows="8"></textarea>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>&nbsp;</td>');
document.write('      <td></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td align="center" valign="middle" colspan="2"><font color="#000000" face="Arial" size="1"><b>Wichtiger Hinweis: Ihre Angaben werden selbstverständlich vertraulich behandelt und keinesfalls an Dritte weitergegeben!');
document.write('<BR>');
document.write('Wir freuen uns, wenn Sie uns Ihr Vertrauen schenken und wir Sie kompetent beraten dürfen!');
document.write('<BR>');
document.write('Senden Sie uns bitte ggf. in Ihrer Nachricht auch Ihre Telefonnummer mit, falls sich kurzfristig wichtige Rückfragen ergeben sollten. ');
document.write('<BR>');
document.write('Gerne können Sie uns aber auch im Rahmen unserer üblichen Geschäftszeiten anrufen!</b></font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>&nbsp;</td>');
document.write('      <td></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td colspan="2" align="center" valign="middle">');
document.write('        <input type="hidden" name="mq" value="\'">');
document.write('        <input type="hidden" name="action" value="send_mail">');
document.write('        <input type="hidden" name="entry" value="90321">');
document.write('        <input type="submit" name="submit" value="Abschicken">');
document.write('        <input type="reset" name="reset" value="Zur&uuml;cksetzen">');
document.write('      </td>');
document.write('    </tr>');
document.write('</form>');
document.write('  </table>');
document.write('');