//icontact-form.js
function verifyRequired() {
  if (document.icpsignup["fields_email"].value == "") {
    document.icpsignup["fields_email"].focus();
    alert("The Email field is required.");
    return false;
  }
  if (document.icpsignup["fields_fname"].value == "") {
    document.icpsignup["fields_fname"].focus();
    alert("The First Name field is required.");
    return false;
  }
  if (document.icpsignup["fields_lname"].value == "") {
    document.icpsignup["fields_lname"].focus();
    alert("The Last Name field is required.");
    return false;
  }
 

return true;
}
document.write('<TABLE cellSpacing=0 cellPadding=0 width=170 border=0>')
document.write('<form method=post action="http://app.icontact.com/icp/signup.php" name="icpsignup" accept-charset="UTF-8" onsubmit="return verifyRequired();" >')
document.write('<input type=hidden name=redirect value="http://www.nhwellnesscenters.com/thanks_signup.html" />')
document.write('<input type=hidden name=errorredirect value="http://www.icontact.com/www/signup/error.html" />')
document.write('<TR>')
document.write('<TD><IMG height=24 src="images/tab_newsletter.gif" width=170 border=0></TD>')
document.write('</TR>')
document.write('</TABLE>')
document.write('<TABLE cellSpacing=0 cellPadding=1 width=170 border=0>')
document.write('<TR>')
document.write('<TD bgColor=#a2a2a2>')
document.write('<TABLE cellPadding=4 width="100%" bgColor=#daeea2>')
document.write('<TR>')
document.write('<TD>')
document.write('<TABLE cellSpacing=0 cellPadding=0 width="100%" border=0>')
document.write('<TR>')
document.write('<TD class=privTxt>')
document.write('<P align=justify>Enter your contact information to receive our FREE report-- "The Seven Underlying Causes of All Health Problems."  Learn how to identify the potential causes of your health challenges and ways to resolve them naturally.')
document.write('<P>')
document.write('Sign up for your report and receive our free email newsletter.')
document.write('<P>Email</P></TD>')
document.write('</TR>')
document.write('<TR>')
document.write('<TD><INPUT title="Your Google Toolbar can fill this in for you. Select AutoFill" style="BACKGROUND-COLOR: #ffffa0" name=fields_email></TD>')
document.write('</TR>')
document.write('<TR>')
document.write('<TD class=privTxt>Last Name</TD>')
document.write('</TR>')
document.write('<TR>')
document.write('<TD><INPUT name=fields_lname style="BACKGROUND-COLOR: #ffffa0"></TD>')
document.write('</TR>')
document.write('<TR>')
document.write('<TD class=privTxt>First Name</TD>')
document.write('</TR>')
document.write('<TR>')
document.write('<TD><INPUT name=fields_fname style="BACKGROUND-COLOR: #ffffa0"></TD>')
document.write('</TR>')
document.write('<INPUT type=hidden value=9870826 name=listid>')
document.write('<input type=hidden name="specialid:9870826" value="LX62">')
document.write('<INPUT type=hidden value=70354 name=clientid>')
document.write('<INPUT type=hidden value=1 name=reallistid>')
document.write('<INPUT type=hidden value=0 name=doubleopt>')
document.write('<TR>')
document.write('<TD class=privTxt><INPUT type=image src="/images/btn_signup.gif" align=right name=Submit></FORM></TD>')
document.write('</TR>')
document.write('</TABLE>')
document.write('</TD>')
document.write('</TR>')
document.write('</TABLE>')
document.write('</TD>')
document.write('</TR>')
document.write('</TABLE>')