function fg_maxchars(n,o) { o.value = o.value.substring(0,n); }
document.write("<style type=\"text/css\">");
document.write("");
document.write("");
document.write("");
document.write(".fg_xform * {");
document.write("");
document.write("  font-family:Arial, Helvetica, sans-serif;");
document.write("");
document.write("  font-size:12px;");
document.write("");
document.write("  color:#FFFFFF;");
document.write("");
document.write("}");
document.write("");
document.write("div.fg_xform select option {");
document.write("");
document.write("  color:#000000 !important;");
document.write("");
document.write("}");
document.write("");
document.write(".fg_xform h1 {");
document.write("");
document.write("  font-size:18px;  ");
document.write("");
document.write("}");
document.write("");
document.write("");
document.write("");
document.write(".fg_xform h2, i ja {");
document.write("");
document.write("  font-size:10px;");
document.write("");
document.write("  font-weight:normal;");
document.write("");
document.write("  margin:0px;");
document.write("");
document.write("  padding:0px;");
document.write("");
document.write("  width:93%;");
document.write("");
document.write("}");
document.write("");
document.write("div.fg_xform {");
document.write("");
document.write("  background-color:#6D2B28;");
document.write("");
document.write("}");
document.write("");
document.write("a.topLink {");
document.write("");
document.write("  display:block;");
document.write("");
document.write("  width:40px;");
document.write("");
document.write("  float:left;");
document.write("");
document.write("  margin:5px 0px 0px 5px;");
document.write("");
document.write("}");
document.write("");
document.write("a.topLink img{");
document.write("");
document.write("  border:0px;");
document.write("");
document.write("}");
document.write("");
document.write("div.columLeft {");
document.write("");
document.write("  width:113px;");
document.write("");
document.write("  float:left;");
document.write("");
document.write("  clear:left;");
document.write("");
document.write("  margin:5px;");
document.write("");
document.write("}");
document.write("");
document.write("div.columLeft span { ");
document.write("");
document.write("  float:left ");
document.write("");
document.write("}");
document.write("");
document.write("div.leftColum {");
document.write("");
document.write("  float:left;");
document.write("");
document.write("  width:200px;");
document.write("");
document.write("  clear:left;");
document.write("");
document.write("}");
document.write("");
document.write(".fg_xform span.pflichtfeld{");
document.write("");
document.write("  display:none;");
document.write("");
document.write("  color:#F00;");
document.write("");
document.write("  width:6px;");
document.write("");
document.write("}");
document.write("");
document.write("div.formField {");
document.write("");
document.write("  float:left;");
document.write("");
document.write("  width:700px;");
document.write("");
document.write("  border:1px solid #CCC;");
document.write("");
document.write("  min-height:500px;");
document.write("");
document.write("  margin-top:0px;");
document.write("");
document.write("  text-align:left;");
document.write("");
document.write("}");
document.write("");
document.write("div.normMargin {");
document.write("");
document.write("  margin:5px;");
document.write("");
document.write("}");
document.write("");
document.write("div.insertItem span {");
document.write("");
document.write("  float:left;");
document.write("");
document.write("  display:block;");
document.write("");
document.write("  margin-top:6px;");
document.write("");
document.write("}");
document.write("");
document.write("div.columRight {");
document.write("");
document.write("  width:396px;");
document.write("");
document.write("  float:left;");
document.write("");
document.write("  margin:5px;");
document.write("");
document.write("}");
document.write("");
document.write("");
document.write("");
document.write("div.extraLeftMargin {");
document.write("");
document.write("  margin-left:10px;");
document.write("");
document.write("  margin-top:0px;");
document.write("");
document.write("}");
document.write("");
document.write("");
document.write("");
document.write("div.formElement {");
document.write("");
document.write("  width:546px;");
document.write("");
document.write("  display:block;");
document.write("");
document.write("  margin:3px;");
document.write("");
document.write("  background-color:#6D2B28;");
document.write("");
document.write("  border: 1px solid #6D2B28;");
document.write("");
document.write("  text-align:left;");
document.write("");
document.write("}");
document.write("");
document.write(".fg_xform input {");
document.write("");
document.write("  cursor:pointer;");
document.write("");
document.write("}");
document.write("");
document.write(".fg_xform span {");
document.write("");
document.write("  cursor:pointer;  ");
document.write("");
document.write("}");
document.write("");
document.write(".fg_xform input[type=text] {");
document.write("");
document.write("  background-color:#6D2B28;");
document.write("");
document.write("  border:1px solid #D9DADB;");
document.write("");
document.write("  color:#FFFFFF;");
document.write("");
document.write("  width:100%;");
document.write("");
document.write("}");
document.write("");
document.write("input.col80 {");
document.write("");
document.write("  width:79% !important;");
document.write("");
document.write("  float:left;");
document.write("");
document.write("  margin-right:1%;");
document.write("");
document.write("}");
document.write("");
document.write("input.col20 {");
document.write("");
document.write("  width:16% !important;");
document.write("");
document.write("  float:right;");
document.write("");
document.write("}");
document.write("");
document.write("input.col70 {");
document.write("");
document.write("  width:69% !important;");
document.write("");
document.write("  float:right;");
document.write("");
document.write("}");
document.write("");
document.write("input.col30 {");
document.write("");
document.write("  width:26% !important;");
document.write("");
document.write("  float:left;");
document.write("");
document.write("}");
document.write("");
document.write(".fg_xform input[type=button] {");
document.write("");
document.write("  background-color:#CCC;");
document.write("");
document.write("  border:1px solid #222;");
document.write("");
document.write("  border-top:1px solid #555;");
document.write("");
document.write("  border-left:1px solid #555;");
document.write("");
document.write("  color:#000;");
document.write("");
document.write("}");
document.write("");
document.write("");
document.write("");
document.write("");
document.write("");
document.write(".fg_xform select {");
document.write("");
document.write("  background-color:#6D2B28;");
document.write("");
document.write("  border:1px solid #D9DADB;");
document.write("");
document.write("  color:#FFFFFF;");
document.write("");
document.write("}");
document.write("");
document.write(".fg_xform input[type=file] {");
document.write("");
document.write("  width:100%;");
document.write("");
document.write("}");
document.write("");
document.write(".fg_xform textarea {");
document.write("");
document.write("  width:100%;");
document.write("");
document.write("  background-color:#6D2B28;");
document.write("");
document.write("  border:1px solid #D9DADB;");
document.write("");
document.write("  color:#FFFFFF;");
document.write("");
document.write("}");
document.write("");
document.write("div.optionsEdit {");
document.write("");
document.write("  position:absolute; ");
document.write("");
document.write("  left:500px; ");
document.write("");
document.write("  top:49px; ");
document.write("");
document.write("  width:220px; ");
document.write("");
document.write("  height:200px;");
document.write("");
document.write("  border:1px solid #000;");
document.write("");
document.write("  border-top:0px;");
document.write("");
document.write("  background-color:#CCCCCC;");
document.write("");
document.write("  padding:5px;");
document.write("");
document.write("}");
document.write("");
document.write("textarea.optionsEditorArea {");
document.write("");
document.write("  width:210px;");
document.write("");
document.write("  height:170px;");
document.write("");
document.write("}");
document.write("");
document.write("img.dragBtn {");
document.write("");
document.write("  border:0px;");
document.write("");
document.write("  cursor:e-resize;");
document.write("");
document.write("}");
document.write("");
document.write("div.editPanel {");
document.write("");
document.write("  display:none;");
document.write("");
document.write("  border:1px solid #333333;");
document.write("");
document.write("  background-color:#CCCCCC;");
document.write("");
document.write("  border-bottom:0px;");
document.write("");
document.write("}");
document.write("");
document.write("img.editPic {");
document.write("");
document.write("  cursor:pointer;");
document.write("");
document.write("}");
document.write("");
document.write("div.propertyWindow {");
document.write("");
document.write("  position:absolute;");
document.write("");
document.write("  width:230px;");
document.write("");
document.write("  border:1px solid #000;");
document.write("");
document.write("  background-color:#CCC;");
document.write("");
document.write("  border-top:0px;");
document.write("");
document.write("  display:none;");
document.write("");
document.write("  padding:5px;");
document.write("");
document.write("}");
document.write("");
document.write("div.propertyLabel {");
document.write("");
document.write("  width:115px;");
document.write("");
document.write("  display:block;");
document.write("");
document.write("  float:left;");
document.write("");
document.write("  clear:left;");
document.write("");
document.write("}");
document.write("");
document.write("a.fg_frog {");
document.write("");
document.write("  display:none;  ");
document.write("");
document.write("}");
document.write("");
document.write("div.propertyValue {");
document.write("");
document.write("  width:115px;");
document.write("");
document.write("  display:block;");
document.write("");
document.write("  float:left;");
document.write("");
document.write("}");
document.write("");
document.write("");
document.write("");
document.write("input.propertyTextInput {");
document.write("");
document.write("  width:120px;");
document.write("");
document.write("  float:left;");
document.write("");
document.write("  height:12px;");
document.write("");
document.write(" }");
document.write("");
document.write("input.propertyIntInput {");
document.write("");
document.write("  width:30px;");
document.write("");
document.write("  float:left;");
document.write("");
document.write("  height:12px;");
document.write("");
document.write(" }");
document.write("");
document.write(" div.radioOption {");
document.write("");
document.write("   float:left; ");
document.write("");
document.write("   display:inline;");
document.write("");
document.write(" }");
document.write("");
document.write(" div.checkboxOption {");
document.write("");
document.write("   float:left; ");
document.write("");
document.write("   display:inline;");
document.write("");
document.write(" }");
document.write("");
document.write("input.capture_input {");
document.write("");
document.write("   clear:left;");
document.write("");
document.write("   width:120px !important;");
document.write("");
document.write("   float:none;");
document.write("");
document.write("   margin-top:3px;");
document.write("");
document.write(" }");
document.write("");
document.write(" div#required_msg_layer {");
document.write("");
document.write("    background-color: #6D2B28;");
document.write("");
document.write("    border: 1px solid #cc0000;");
document.write("");
document.write("    color: #FFFFFF;");
document.write("");
document.write("");
document.write("");
document.write("background: -moz-linear-gradient(top, #fcfff4 0%, #e9e9ce 100%); /* FF3.6+ */");
document.write("");
document.write("background: -webkit-gradient(linear, left top, left bottom, color-stop(0%,#fcfff4), color-stop(100%,#e9e9ce)); /* Chrome,Safari4+ */");
document.write("");
document.write("background: -webkit-linear-gradient(top, #fcfff4 0%,#e9e9ce 100%); /* Chrome10+,Safari5.1+ */");
document.write("");
document.write("background: -o-linear-gradient(top, #fcfff4 0%,#e9e9ce 100%); /* Opera 11.10+ */");
document.write("");
document.write("background: -ms-linear-gradient(top, #fcfff4 0%,#e9e9ce 100%); /* IE10+ */");
document.write("");
document.write("background: linear-gradient(top, #fcfff4 0%,#e9e9ce 100%); /* W3C */");
document.write("");
document.write("filter: progid:DXImageTransform.Microsoft.gradient( startColorstr='#fcfff4', endColorstr='#e9e9ce',GradientType=0 ); /* IE6-9 */");
document.write("");
document.write("  ");
document.write("");
document.write("  background-clip: padding-box;");
document.write("");
document.write("    border: 12px solid rgba(6, 109, 171, 0.7);");
document.write("");
document.write("    height: auto;");
document.write("");
document.write("    left: -9999px;");
document.write("");
document.write("    min-height: 100px;");
document.write("");
document.write("    position: absolute;");
document.write("");
document.write("    top: -9999px;");
document.write("");
document.write("    width: 320px;");
document.write("");
document.write("  display:none;");
document.write("");
document.write("}");
document.write("");
document.write("div#required_msg_layer #error_msg {");
document.write("");
document.write("    height: auto;");
document.write("");
document.write("    margin: 30px auto;");
document.write("");
document.write("    min-height: 50px;");
document.write("");
document.write("    width: 220px;");
document.write("");
document.write("}");
document.write("");
document.write("div#required_msg_layer #error_msg p {");
document.write("");
document.write("    font-size: 12px;");
document.write("");
document.write("    font-weight: bold;");
document.write("");
document.write("}");
document.write("");
document.write("div#required_msg_layer #error_msg ul {");
document.write("");
document.write("    font-size: 12px;");
document.write("");
document.write("    font-weight: bold;");
document.write("");
document.write("}");
document.write("");
document.write("ul.ul_error{");
document.write("");
document.write("margin:0 0 15px 0;");
document.write("");
document.write("list-style:none;");
document.write("");
document.write("background-image:none;");
document.write("");
document.write("padding-left:5px;");
document.write("");
document.write("");
document.write("");
document.write("}");
document.write("");
document.write("#error_msg li{");
document.write("");
document.write("margin:0;");
document.write("");
document.write("padding:0;");
document.write("");
document.write("background-image:none;");
document.write("");
document.write("list-style:square;");
document.write("");
document.write("text-align:left;");
document.write("");
document.write("color:#666;");
document.write("");
document.write("}");
document.write("");
document.write("div#required_msg_layer #btnClose {");
document.write("");
document.write("    cursor: pointer;");
document.write("");
document.write("    position: absolute;");
document.write("");
document.write("    right: 5px;");
document.write("");
document.write("    top: 5px;");
document.write("");
document.write("}");
document.write("");
document.write("span.fill_required {");
document.write("");
document.write("  font-weight:bold;");
document.write("");
document.write("  color:#cc0000;");
document.write("");
document.write("  ");
document.write("");
document.write("}");
document.write("");
document.write(".input_required {");
document.write("");
document.write("    background:url(https://www.cmsfrog.de/form_generator/images/required.png) right center no-repeat #ffc8c8 !important;");
document.write("");
document.write("    border:1px solid #cc0000 !important;");
document.write("");
document.write("}");
document.write("");
document.write(".fg_xform input[type=text]{");
document.write("");
document.write("  cursor:text;");
document.write("");
document.write("}");
document.write("");
document.write(".columLeft span{");
document.write("");
document.write("cursor:text;");
document.write("");
document.write("}");
document.write("");
document.write(".fg_xform .columRight img {");
document.write("");
document.write("  width:auto;  ");
document.write("");
document.write("}");
document.write("");
document.write("img{");
document.write("");
document.write("  border:0 !important;");
document.write("");
document.write("  padding:0 !important;");
document.write("");
document.write("}");
document.write("");
document.write("</style>");
document.write("<div id=\"required_msg_layer\">\n");
document.write("  <img src=\"https://www.cmsfrog.de/form_generator/close.png\" id=\"btnClose\"/>\n");
document.write("    <div id=\"error_msg\">\n");
document.write("    <p>Fett markierte Felder sind Pflichtfelder</p>\n");
document.write("\n");
document.write("    </div>\n");
document.write("</div><div id='fg_xform' class='fg_xform'><form id='fg_xform_form' action='https://www.cmsfrog.de/form_generator/submit.php?c=1e9531ee340b548a407dc6b220ee0f31&PHPSESSID=e20104aaa03d2cffff131823ebf9d277' enctype='multipart/form-data' method='post'>");
document.write("<div id=\"tpl_h1\" class=\"formElement\">");
document.write("    <div class=\"normMargin\">");
document.write("    <h1 style=\"font-size:12px\">Persönliche Angaben</h1>");
document.write("    </div>");
document.write("  </div>");
document.write("  <div id=\"tpl_select\" class=\"formElement\">");
document.write("    <div class=\"columLeft\"><span>Anrede</span>");
document.write("      <span class=\"pflichtfeld\">*</span>");
document.write("    </div>");
document.write("    <div class=\"columRight\"><select name=\"form_input_1\"><option selected>Bitte w&auml;hlen...</option><option>Frau</option><option>Herr</option></select></div>");
document.write("    <div style=\"clear:left\"></div>");
document.write("  </div>");
document.write("  <div id=\"tpl_text\" class=\"formElement\">");
document.write("    <div class=\"columLeft\"><span>Vorname:</span>");
document.write("      <span class=\"pflichtfeld\" style=\"display:inline\">*</span>");
document.write("    </div>");
document.write("    <div class=\"columRight\">");
document.write("      <input style=\"\" name=\"form_input_2\" value=\"\"type = \"text\" />");
document.write("    </div>");
document.write("    <div style=\"clear:left\"></div>");
document.write("  </div>");
document.write("  <div id=\"tpl_text\" class=\"formElement\">");
document.write("    <div class=\"columLeft\"><span>Name:</span>");
document.write("      <span class=\"pflichtfeld\" style=\"display:inline\">*</span>");
document.write("    </div>");
document.write("    <div class=\"columRight\">");
document.write("      <input style=\"\" name=\"form_input_3\" value=\"\"type = \"text\" />");
document.write("    </div>");
document.write("    <div style=\"clear:left\"></div>");
document.write("  </div>");
document.write("  <div id=\"tpl_street\" class=\"formElement\">");
document.write("    <div class=\"columLeft\"><span>Strasse / Nr:</span>");
document.write("      <span class=\"pflichtfeld\" style=\"display:inline\">*</span>");
document.write("    </div>");
document.write("    <div class=\"columRight\">");
document.write("      <input   type = \"text\" class=\"col80\" name=\"form_input_4\" value=\"\" /> <input type = \"text\" class=\"col20\" name=\"form_input_4\" value=\"\" />");
document.write("    </div>");
document.write("    <div style=\"clear:left\"></div>");
document.write("  </div>");
document.write("  <div id=\"tpl_city\" class=\"formElement\">");
document.write("    <div class=\"columLeft\"><span>Plz / Ort:</span>");
document.write("      <span class=\"pflichtfeld\" style=\"display:inline\">*</span>");
document.write("    </div>");
document.write("    <div class=\"columRight\">");
document.write("      <input   type = \"text\" class=\"col30\" name=\"form_input_5\" value=\"\" /> <input type = \"text\" class=\"col70\" name=\"form_input_5\" value=\"\" />");
document.write("    </div>");
document.write("    <div style=\"clear:left\"></div>");
document.write("  </div>");
document.write("  <div id=\"tpl_text\" class=\"formElement\">");
document.write("    <div class=\"columLeft\"><span>Telefon:</span>");
document.write("      <span class=\"pflichtfeld\" style=\"display:inline\">*</span>");
document.write("    </div>");
document.write("    <div class=\"columRight\">");
document.write("      <input style=\"\" name=\"form_input_6\" value=\"\"type = \"text\" />");
document.write("    </div>");
document.write("    <div style=\"clear:left\"></div>");
document.write("  </div>");
document.write("  <div id=\"tpl_text\" class=\"formElement\">");
document.write("    <div class=\"columLeft\"><span>Mobil:</span>");
document.write("      <span class=\"pflichtfeld\">*</span>");
document.write("    </div>");
document.write("    <div class=\"columRight\">");
document.write("      <input style=\"\" name=\"form_input_7\" value=\"\"type = \"text\" />");
document.write("    </div>");
document.write("    <div style=\"clear:left\"></div>");
document.write("  </div>");
document.write("  <div id=\"tpl_email\" class=\"formElement\">");
document.write("    <div class=\"columLeft\"><span>Email:</span>");
document.write("      <span class=\"pflichtfeld\" style=\"display:inline\">*</span>");
document.write("    </div>");
document.write("    <div class=\"columRight\">");
document.write("      <input maxlength=\"40\" style=\"\" name=\"form_input_8\" value=\"\"type = \"text\" />");
document.write("    </div>");
document.write("    <div style=\"clear:left\"></div>");
document.write("  </div>");
document.write("  <div id=\"tpl_text\" class=\"formElement\">");
document.write("    <div class=\"columLeft\"><span>Geburtsdatum:</span>");
document.write("      <span class=\"pflichtfeld\" style=\"display:inline\">*</span>");
document.write("    </div>");
document.write("    <div class=\"columRight\">");
document.write("      <input style=\"\" name=\"form_input_9\" value=\"\"type = \"text\" />");
document.write("    </div>");
document.write("    <div style=\"clear:left\"></div>");
document.write("  </div>");
document.write("  <div id=\"tpl_select\" class=\"formElement\">");
document.write("    <div class=\"columLeft\"><span>Krankenkasse:</span>");
document.write("      <span class=\"pflichtfeld\" style=\"display:inline\">*</span>");
document.write("    </div>");
document.write("    <div class=\"columRight\"><select name=\"form_input_10\"><option selected>Bitte w&auml;hlen...</option><option>Gesetzlich</option><option>Privat</option><option>BG (Berufsgenossenschaft)</option><option>Bundeswehr</option></select></div>");
document.write("    <div style=\"clear:left\"></div>");
document.write("  </div>");
document.write("  <div id=\"tpl_h1\" class=\"formElement\">");
document.write("    <div class=\"normMargin\">");
document.write("    <h1 style=\"font-size:12px\">Ergänzende Angaben auf dem Privatrezept,der Heilmittelverordnung oder BG-Verordnung:</h1>");
document.write("    </div>");
document.write("  </div>");
document.write("  <div id=\"tpl_checkbox\" class=\"formElement\">");
document.write("    <div class=\"columLeft\"><span>Termin für:</span>");
document.write("      <span class=\"pflichtfeld\" style=\"display:inline\">*</span>");
document.write("    </div>");
document.write("    <div class=\"columRight\"><div class=\"checkboxOption\" style=\"clear:left;width:50%\"><input type =\"checkbox\" value=\"kPNI / Osteopathie\" name=\"form_input_12[]\" /> <span>kPNI / Osteopathie</span></div><div class=\"checkboxOption\" style=\"width:50%\"><input type =\"checkbox\" value=\"Manuelle Therapie\" name=\"form_input_12[]\" /> <span>Manuelle Therapie</span></div><div class=\"checkboxOption\" style=\"clear:left;width:50%\"><input type =\"checkbox\" value=\"FDM n. Typaldos\" name=\"form_input_12[]\" /> <span>FDM n. Typaldos</span></div><div class=\"checkboxOption\" style=\"width:50%\"><input type =\"checkbox\" value=\"Krankengymnastik\" name=\"form_input_12[]\" /> <span>Krankengymnastik</span></div><div class=\"checkboxOption\" style=\"clear:left;width:50%\"><input type =\"checkbox\" value=\"Krangengymnastik n. Bobath\" name=\"form_input_12[]\" /> <span>Krangengymnastik n. Bobath</span></div><div class=\"checkboxOption\" style=\"width:50%\"><input type =\"checkbox\" value=\"Krankengymnastik am Ger&auml;t\" name=\"form_input_12[]\" /> <span>Krankengymnastik am Ger&auml;t</span></div><div class=\"checkboxOption\" style=\"clear:left;width:50%\"><input type =\"checkbox\" value=\"Massage\" name=\"form_input_12[]\" /> <span>Massage</span></div><div class=\"checkboxOption\" style=\"width:50%\"><input type =\"checkbox\" value=\"Lymphdrainage 30 Minuten\" name=\"form_input_12[]\" /> <span>Lymphdrainage 30 Minuten</span></div><div class=\"checkboxOption\" style=\"clear:left;width:50%\"><input type =\"checkbox\" value=\"W&auml;rmetherapie (Moor/Hei&szlig;luft)\" name=\"form_input_12[]\" /> <span>W&auml;rmetherapie (Moor/Hei&szlig;luft)</span></div><div class=\"checkboxOption\" style=\"width:50%\"><input type =\"checkbox\" value=\"Lymphdrainage 45 Minuten\" name=\"form_input_12[]\" /> <span>Lymphdrainage 45 Minuten</span></div><div class=\"checkboxOption\" style=\"clear:left;width:50%\"><input type =\"checkbox\" value=\"Physioveda\" name=\"form_input_12[]\" /> <span>Physioveda</span></div><div class=\"checkboxOption\" style=\"width:50%\"><input type =\"checkbox\" value=\"Training Refresher \" name=\"form_input_12[]\" /> <span>Training Refresher </span></div><div class=\"checkboxOption\" style=\"clear:left;width:50%\"><input type =\"checkbox\" value=\"im Hausbesuch (ortsnah)\" name=\"form_input_12[]\" /> <span>im Hausbesuch (ortsnah)</span></div></div><div style=\"clear:left\"></div>");
document.write("  </div>");
document.write("  <div id=\"tpl_text\" class=\"formElement\">");
document.write("    <div class=\"columLeft\"><span>Ausstellungsdatum:</span>");
document.write("      <span class=\"pflichtfeld\">*</span>");
document.write("    </div>");
document.write("    <div class=\"columRight\">");
document.write("      <input style=\"\" name=\"form_input_13\" value=\"\"type = \"text\" />");
document.write("    </div>");
document.write("    <div style=\"clear:left\"></div>");
document.write("  </div>");
document.write("  <div id=\"tpl_text\" class=\"formElement\">");
document.write("    <div class=\"columLeft\"><span>Behandlungsbeginn:</span>");
document.write("      <span class=\"pflichtfeld\">*</span>");
document.write("    </div>");
document.write("    <div class=\"columRight\">");
document.write("      <input style=\"\" name=\"form_input_14\" value=\"\"type = \"text\" />");
document.write("    </div>");
document.write("    <div style=\"clear:left\"></div>");
document.write("  </div>");
document.write("  <div id=\"tpl_text\" class=\"formElement\">");
document.write("    <div class=\"columLeft\"><span>Anzahl pro Woche:</span>");
document.write("      <span class=\"pflichtfeld\">*</span>");
document.write("    </div>");
document.write("    <div class=\"columRight\">");
document.write("      <input style=\"\" name=\"form_input_15\" value=\"\"type = \"text\" />");
document.write("    </div>");
document.write("    <div style=\"clear:left\"></div>");
document.write("  </div>");
document.write("  <div id=\"tpl_h1\" class=\"formElement\">");
document.write("    <div class=\"normMargin\">");
document.write("    <h1 style=\"font-size:14px\">Bitte senden Sie uns schon vorab ein Foto von der Verordnung per Datei-Upload oder per WhatsApp (die persönlichen Daten können Sie abdecken)</h1>");
document.write("    </div>");
document.write("  </div>");
document.write("  <div id=\"tpl_file\" class=\"formElement\">");
document.write("    <div class=\"columLeft\"><span>Zur Bearbeitung klicken:</span>");
document.write("      <span class=\"pflichtfeld\">*</span>");
document.write("    </div>");
document.write("    <div class=\"columRight\">");
document.write("      <input name=\"form_input_17\" type =\"file\" />");
document.write("    </div>");
document.write("    <div style=\"clear:left\"></div>");
document.write("  </div>");
document.write("  <div id=\"tpl_h1\" class=\"formElement\">");
document.write("    <div class=\"normMargin\">");
document.write("    <h1 style=\"font-size:12px\">Bitte geben Sie ein Zeitfenster für Ihre Terminwünsche an:</h1>");
document.write("    </div>");
document.write("  </div>");
document.write("  <div id=\"tpl_checkbox\" class=\"formElement\">");
document.write("    <div class=\"columLeft\"><span>Mögliche Tage:</span>");
document.write("      <span class=\"pflichtfeld\">*</span>");
document.write("    </div>");
document.write("    <div class=\"columRight\"><div class=\"checkboxOption\" style=\"clear:left;width:50%\"><input type =\"checkbox\" value=\"Montag\" name=\"form_input_19[]\" /> <span>Montag</span></div><div class=\"checkboxOption\" style=\"width:50%\"><input type =\"checkbox\" value=\"Donnerstag\" name=\"form_input_19[]\" /> <span>Donnerstag</span></div><div class=\"checkboxOption\" style=\"clear:left;width:50%\"><input type =\"checkbox\" value=\"Dienstag\" name=\"form_input_19[]\" /> <span>Dienstag</span></div><div class=\"checkboxOption\" style=\"width:50%\"><input type =\"checkbox\" value=\"Freitag\" name=\"form_input_19[]\" /> <span>Freitag</span></div><div class=\"checkboxOption\" style=\"clear:left;width:50%\"><input type =\"checkbox\" value=\"Mittwoch\" name=\"form_input_19[]\" /> <span>Mittwoch</span></div></div><div style=\"clear:left\"></div>");
document.write("  </div>");
document.write("  <div id=\"tpl_checkbox\" class=\"formElement\">");
document.write("    <div class=\"columLeft\"><span>Mögliche Zeiten:</span>");
document.write("      <span class=\"pflichtfeld\">*</span>");
document.write("    </div>");
document.write("    <div class=\"columRight\"><div class=\"checkboxOption\" style=\"clear:left;width:50%\"><input type =\"checkbox\" value=\"eher vormittags\" name=\"form_input_20[]\" /> <span>eher vormittags</span></div><div class=\"checkboxOption\" style=\"width:50%\"><input type =\"checkbox\" value=\"eher abends\" name=\"form_input_20[]\" /> <span>eher abends</span></div><div class=\"checkboxOption\" style=\"clear:left;width:50%\"><input type =\"checkbox\" value=\"eher mittags\" name=\"form_input_20[]\" /> <span>eher mittags</span></div><div class=\"checkboxOption\" style=\"width:50%\"><input type =\"checkbox\" value=\"jederzeit\" name=\"form_input_20[]\" /> <span>jederzeit</span></div><div class=\"checkboxOption\" style=\"clear:left;width:50%\"><input type =\"checkbox\" value=\"eher nachmittags\" name=\"form_input_20[]\" /> <span>eher nachmittags</span></div></div><div style=\"clear:left\"></div>");
document.write("  </div>");
document.write("  <div id=\"tpl_checkbox\" class=\"formElement\">");
document.write("    <div class=\"columLeft\"><span>Möglichst bei:</span>");
document.write("      <span class=\"pflichtfeld\">*</span>");
document.write("    </div>");
document.write("    <div class=\"columRight\"><div class=\"checkboxOption\" style=\"clear:left;width:50%\"><input type =\"checkbox\" value=\"Dirk B&ouml;hning\" name=\"form_input_21[]\" /> <span>Dirk B&ouml;hning</span></div><div class=\"checkboxOption\" style=\"width:50%\"><input type =\"checkbox\" value=\"Severina B&ouml;hning\" name=\"form_input_21[]\" /> <span>Severina B&ouml;hning</span></div><div class=\"checkboxOption\" style=\"clear:left;width:50%\"><input type =\"checkbox\" value=\"Frank Lehwald\" name=\"form_input_21[]\" /> <span>Frank Lehwald</span></div><div class=\"checkboxOption\" style=\"width:50%\"><input type =\"checkbox\" value=\"Jenny R&ouml;mhild\" name=\"form_input_21[]\" /> <span>Jenny R&ouml;mhild</span></div><div class=\"checkboxOption\" style=\"clear:left;width:50%\"><input type =\"checkbox\" value=\"Ich lass mich &uuml;berraschen\" name=\"form_input_21[]\" /> <span>Ich lass mich &uuml;berraschen</span></div></div><div style=\"clear:left\"></div>");
document.write("  </div>");
document.write("  <div id=\"tpl_text\" class=\"formElement\">");
document.write("    <div class=\"columLeft\"><span>Wann können wir Sie am besten erreichen?</span>");
document.write("      <span class=\"pflichtfeld\" style=\"display:inline\">*</span>");
document.write("    </div>");
document.write("    <div class=\"columRight\">");
document.write("      <input style=\"\" name=\"form_input_22\" value=\"\"type = \"text\" />");
document.write("    </div>");
document.write("    <div style=\"clear:left\"></div>");
document.write("  </div>");
document.write("  <div id=\"tpl_textarea\" class=\"formElement\">");
document.write("    <div class=\"columLeft\"><span>Bemerkungen:</span>");
document.write("      <span class=\"pflichtfeld\">*</span>");
document.write("    </div>");
document.write("    <div class=\"columRight\">");
document.write("       <textarea style=\"height:53px;\" name=\"form_input_23\" ></textarea>");
document.write("    </div>");
document.write("    <div style=\"clear:left\"></div>");
document.write("  </div>");
document.write("  <div id=\"tpl_submit\" class=\"formElement\">");
document.write("   <div class=\"columLeft\">");
document.write("    </div>");
document.write("    <div class=\"columRight\">");
document.write("      <input type =\"button\" value=\"abschicken\" onclick=\"startCheck()\" />");
document.write("    </div>");
document.write("    <div style=\"clear:left\"></div>");
document.write("  </div>");
document.write("  ");
document.write("</form></div>");

function aCheck() {if (!document.getElementById('fg_link') || document.getElementById('fg_link').rel=='nofollow' || document.getElementById('fg_link').href!='http://www.cmsfrog.de/' || document.getElementById('fg_link').innerHTML.indexOf('CMS Frog')==-1) document.getElementById('fg_xform').style.display='none';} window.setTimeout('aCheck()',100); var hasFlash = false;
try {
  var fo = new ActiveXObject('ShockwaveFlash.ShockwaveFlash');
  if(fo) hasFlash = true;
}catch(e){
  if(navigator.mimeTypes ["application/x-shockwave-flash"] != undefined) hasFlash = true;
}

function getSWF(strName) {

        if (window.document[strName] != null)
            if (window.document[strName].length == null)
                return window.document[strName];
            else
                return window.document[strName][1];
        else
            if (document[strName].length == null)
                return document[strName];
            else
                return document[strName][1];

 }

function AC_AddExtension(src, ext)
{
  if (src.indexOf('?') != -1)
    return src.replace(/\?/, ext+'?'); 
  else
    return src + ext;
}

function AC_Generateobj(objAttrs, params, embedAttrs, returnStr) 
{ 
  var str = '<object ';
  for (var i in objAttrs)
    if (i != "name")
      str += i + '="' + objAttrs[i] + '" ';
  str += '>';
  for (var i in params)
    if (i != "id")
      str += '<param name="' + i + '" value="' + params[i] + '"  /> ';
  str += '<embed ';
  for (var i in embedAttrs)
    if (i != "id")
      str += i + '="' + embedAttrs[i] + '" ';
  str += ' ></embed></object>';

  if (returnStr == null)
    document.write(str); else
      return str;
}

function AC_FL_RunContent(){
  var ret = 
    AC_GetArgs
    (  arguments, ".swf", "movie", "clsid:d27cdb6e-ae6d-11cf-96b8-444553540000"
     , "application/x-shockwave-flash"
    );
  AC_Generateobj(ret.objAttrs, ret.params, ret.embedAttrs);
}

function AC_FL_ReturnContent(){
  var ret = 
    AC_GetArgs
    (  arguments, ".swf", "movie", "clsid:d27cdb6e-ae6d-11cf-96b8-444553540000"
     , "application/x-shockwave-flash"
    );
  return AC_Generateobj(ret.objAttrs, ret.params, ret.embedAttrs, 1);
}


function AC_SW_RunContent(){
  var ret = 
    AC_GetArgs
    (  arguments, ".dcr", "src", "clsid:166B1BCA-3F9C-11CF-8075-444553540000"
     , null
    );
  AC_Generateobj(ret.objAttrs, ret.params, ret.embedAttrs);
}

function AC_GetArgs(args, ext, srcParamName, classid, mimeType){
  var ret = new Object();
  ret.embedAttrs = new Object();
  ret.params = new Object();
  ret.objAttrs = new Object();
  for (var i=0; i < args.length; i=i+2){
    var currArg = args[i].toLowerCase();    

    switch (currArg){  
      case "classid":
        break;
      case "pluginspage":
        ret.embedAttrs[args[i]] = args[i+1];
        break;
      case "src":
      case "movie":  
        args[i+1] = AC_AddExtension(args[i+1], ext);
        ret.embedAttrs["src"] = args[i+1];
        ret.params[srcParamName] = args[i+1];
        break;
      case "onafterupdate":
      case "onbeforeupdate":
      case "onblur":
      case "oncellchange":
      case "onclick":
      case "ondblClick":
      case "ondrag":
      case "ondragend":
      case "ondragenter":
      case "ondragleave":
      case "ondragover":
      case "ondrop":
      case "onfinish":
      case "onfocus":
      case "onhelp":
      case "onmousedown":
      case "onmouseup":
      case "onmouseover":
      case "onmousemove":
      case "onmouseout":
      case "onkeypress":
      case "onkeydown":
      case "onkeyup":
      case "onload":
      case "onlosecapture":
      case "onpropertychange":
      case "onreadystatechange":
      case "onrowsdelete":
      case "onrowenter":
      case "onrowexit":
      case "onrowsinserted":
      case "onstart":
      case "onscroll":
      case "onbeforeeditfocus":
      case "onactivate":
      case "onbeforedeactivate":
      case "ondeactivate":
      case "type":
      case "codebase":
        ret.objAttrs[args[i]] = args[i+1];
        break;
      case "width":
      case "height":
      case "align":
      case "vspace": 
      case "hspace":
      case "class":
      case "title":
      case "accesskey":
      case "name":
      case "id":
      case "tabindex":
        ret.embedAttrs[args[i]] = ret.objAttrs[args[i]] = args[i+1];
        break;
      default:
        ret.embedAttrs[args[i]] = ret.params[args[i]] = args[i+1];
    }
  }
  ret.objAttrs["classid"] = classid;
  if (mimeType) ret.embedAttrs["type"] = mimeType;
  return ret;
}

function submit_func(){
  // do nothing
}
var captcha_code=false;

function mergeMultiFields() {
  var fields = document.getElementsByTagName("input");
  var mergedValues = new Array();
  for (var i=0;i<fields.length;i++) {
    if (fields[i].type == 'radio' || fields[i].name.indexOf('[]')!=-1) continue;
    for (j=0;j<fields.length;j++)
      if (fields[j].name == fields[i].name && fields[j] != fields[i])
        mergedValues[fields[j].name] = fields[j].value + " " + fields[i].value;
  }
  for (var i=0;i<fields.length;i++) {
  if (fields[i].type != "button")
    if (mergedValues[fields[i].name])
      fields[i].value = mergedValues[fields[i].name];
  }
}

function startCheck() {
 formCheck();
}

function hidden_valid_call(v) {
  captcha_code = v;
  formCheck();
}

function setPlichtfeldClass(label_span){
  if (label_span == null) return;
  if (label_span.tagName == 'SPAN')  
    label_span.className += ' fill_required';  

  if (label_span.parentNode.parentNode.getElementsByTagName('input').length) {
    for (i=0;i<label_span.parentNode.parentNode.getElementsByTagName('input').length;i++) label_span.parentNode.parentNode.getElementsByTagName('input')[i].className += ' input_required';
  }
  if (label_span.parentNode.parentNode.getElementsByTagName('textarea').length) {
    for (i=0;i<label_span.parentNode.parentNode.getElementsByTagName('textarea').length;i++) label_span.parentNode.parentNode.getElementsByTagName('textarea')[i].className += ' input_required';
  }
  if (label_span.parentNode.parentNode.getElementsByTagName('select').length) {
    for (i=0;i<label_span.parentNode.parentNode.getElementsByTagName('select').length;i++) label_span.parentNode.parentNode.getElementsByTagName('select')[i].className += ' input_required';
  }
}

function removePlichtfeldClass(label_span){
  if (label_span == null) return;
  if (label_span.tagName == 'SPAN')  
    label_span.className = label_span.className.replace(/fill_required/g,'');  
  if (label_span.parentNode.parentNode.getElementsByTagName('input').length) {
    for (i=0;i<label_span.parentNode.parentNode.getElementsByTagName('input').length;i++) 
      label_span.parentNode.parentNode.getElementsByTagName('input')[i].className = label_span.parentNode.parentNode.getElementsByTagName('input')[i].className.replace(/input_required/g,'');
  }
  if (label_span.parentNode.parentNode.getElementsByTagName('textarea').length) {
    for (i=0;i<label_span.parentNode.parentNode.getElementsByTagName('textarea').length;i++) 
      label_span.parentNode.parentNode.getElementsByTagName('textarea')[i].className = label_span.parentNode.parentNode.getElementsByTagName('textarea')[i].className.replace(/input_required/g,'');
  }
  if (label_span.parentNode.parentNode.getElementsByTagName('select').length) {
    for (i=0;i<label_span.parentNode.parentNode.getElementsByTagName('select').length;i++) 
      label_span.parentNode.parentNode.getElementsByTagName('select')[i].className = label_span.parentNode.parentNode.getElementsByTagName('select')[i].className.replace(/input_required/g,'');
  }
}

function nextDiv(elm) {
  var n = elm;
  while (n.nextSibling && n.nextSibling.tagName != "DIV") {
    n = n.nextSibling;
  }
  if (n.tagName != "DIV") return elm; else return n;
}

function compare_captcha() {
  if (!document.getElementById('kk_key')) { captcha_code = 1; return; }
  var k = document.getElementById('kk_key').value;
  if (k!=0)
    var v = document.getElementById('hidden_captcha_' + k).value; else
      var v = document.getElementById('hidden_captcha').value;
  var entry = document.getElementById('capture').value;
  
  var e = '';
  for (var i=0;i<v.length;i++) {
  var c = (v.charCodeAt(i)-k%256);
  e += String.fromCharCode(c&&Math.sqrt(Math.pow(Math.E)));
  }
  //alert(v + " : " + e + " : " + k + " : " + entry);
  if (v.toLowerCase() == entry.toLowerCase()) captcha_code = 1; else captcha_code = false;
}

function formCheck() {
  var pflichtfelder = new Array();
  sendok=true;
  
    var sendok=true;
    var missing_input=false;
    var missing_input_msg = '';
    
    var pflichtfeld_spans = document.getElementById('fg_xform').getElementsByTagName('span');
  
    for (var i = 0; i<pflichtfeld_spans.length;i++) {
      if (pflichtfeld_spans[i].className.indexOf('pflichtfeld')==-1) continue;
      if (pflichtfeld_spans[i].style.display != "block" && pflichtfeld_spans[i].style.display != "inline") continue;
      var p = pflichtfeld_spans[i].parentNode.parentNode;
      var inputs = p.getElementsByTagName("input");
      for (j = 0; j<inputs.length; j++) {
      pflichtfelder[pflichtfelder.length]=inputs[j];
      }
      var inputs = p.getElementsByTagName("textarea");
      for (j = 0; j<inputs.length; j++) {
      pflichtfelder[pflichtfelder.length]=inputs[j];
      }
      var inputs = p.getElementsByTagName("select");
      for (j = 0; j<inputs.length; j++) {
      pflichtfelder[pflichtfelder.length]=inputs[j];
      }
    }
    

    for (var i=0;i<pflichtfelder.length;i++) {
      var bf = pflichtfelder[i];
      if (bf.parentNode)
        var label=bf.parentNode.parentNode.getElementsByTagName("div")[0].getElementsByTagName('span')[0]; else label = null;
      if ((bf.type == 'radio' || bf.type == 'checkbox'))
        var label=bf.parentNode.parentNode.parentNode.getElementsByTagName("div")[0].getElementsByTagName('span')[0];
      removePlichtfeldClass(label)
      var pflichtfeld = bf;
      switch(pflichtfeld.tagName.toLowerCase()){
        case 'input':
          if ((pflichtfeld.type == 'radio' || pflichtfeld.type == 'checkbox')) {
            
            var arr = eval('document.forms["fg_xform_form"].elements');
             
            var ch = false;
            for (var j=0;j<arr.length;j++) {
              if (arr[j].name == pflichtfeld.name) {
                if (arr[j].checked) ch = true;
              }
            }
            if (!ch) {
            sendok=false;
            missing_input_msg="\n\nFett markierte Felder müssen ausgefüllt werden\n\n";
            
            setPlichtfeldClass(label);
            }
          } else
          if(pflichtfeld.value==''){
            if (pflichtfeld.type == 'radio' || pflichtfeld.type == 'checkbox') continue;
            sendok=false;
            missing_input_msg="\n\nFett markierte Felder müssen ausgefüllt werden\n\n";
            
            setPlichtfeldClass(label)
          }
        break;
        case 'textarea':
          if(pflichtfeld.value==''){
            sendok=false;
            missing_input_msg="\n\nFett markierte Felder müssen ausgefüllt werden\n\n";
            setPlichtfeldClass(label)
          }
        break;
        case 'select':
          if(pflichtfeld.options.selectedIndex==0){
            sendok=false;
            missing_input_msg="\n\nFett markierte Felder müssen ausgefüllt werden\n\n";
            setPlichtfeldClass(label)
          }
        break;
      }
    }
    var wrong_capture_msg='';
    compare_captcha();
    if(document.getElementById('capture'))
    if(captcha_code != 1){
      sendok=false;
      wrong_capture_msg="\n\nCaptcha Text wurde nicht richtig eingetragen\n\n";
    }else
      wrong_capture_msg='';
    if(sendok==false){
      var btnClose=document.getElementById('btnClose');
      
      btnClose.onclick = hideMsg;
      
      if (wrong_capture_msg!='')
        alert(wrong_capture_msg);
      
      
    }else{
      mergeMultiFields();
      
      document.getElementById('fg_xform_form').submit();
      
    }
    
  }
  
function getScrollXY() {
    var scrOfX = 0, scrOfY = 0;
    if( typeof( window.pageYOffset ) == 'number' ) {
      //Netscape compliant
      scrOfY = window.pageYOffset;
      scrOfX = window.pageXOffset;
    } else if( document.body && ( document.body.scrollLeft || document.body.scrollTop ) ) {
      //DOM compliant
      scrOfY = document.body.scrollTop;
      scrOfX = document.body.scrollLeft;
    } else if( document.documentElement && ( document.documentElement.scrollLeft || document.documentElement.scrollTop ) ) {
      //IE6 standards compliant mode
      scrOfY = document.documentElement.scrollTop;
      scrOfX = document.documentElement.scrollLeft;
    }
    return [ scrOfX, scrOfY ];
  }


  
  
  
  function hideMsg(){
    document.getElementById('required_msg_layer').style.left = '-9999px';
    document.getElementById('required_msg_layer').style.top = '-9999px';
  }  
    
  var missing_input_msg=false;
  var wrong_captcha_msg=false;

  function cDebug(obj){
    if(typeof console !='undefined')
      console.log(obj)
  }