ÿþ<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 3.2//EN"> <HTML> <HEAD> <TITLE> Tidsbestilling - hos Tandlæge Jette Stepputat </TITLE> <META NAME="keywords" CONTENT="tandlæger"> <META NAME="descreption" CONTENT="tandlæger "> <table cellpadding=0 cellspacing=0> <TR> <TD> <br> <FORM action="http://www.mira.dk/cgi-bin/FormMail.pl" method="POST" target="new"> <input type=hidden name=recipient value=jette@stepputat.dk> <input type=hidden name=required value="Fornavn, Efternavn, CPR, Telefon"> <input type=hidden name=env_report value="REMOTE_ADDR, HTTP_USER_AGENT"> <input type=hidden name=sort value=""> <input type=hidden name=title value="Tak for dine oplysninger, vi kontakter dig snarest"> <input type=hidden name=return_link_title value="Tilbage til hovedesiden"> <input type=hidden name=return_link_url value="http://www.stepputat.dk/"> <input type=hidden name=background value=""> <input type=hidden name=text_color value=#000000> <P><font size="4" face="swis721 Cn BT">TIDSBESTILLING: </P> <table cellpadding=2 cellspacing=2> <tr> <TD> <font size="3" face="swis721 Cn BT">Indtast dine oplysninger:</FONT> </TD> <TD> </TD> </tr> <tr> <TD align="right"> <font size="3" face="swis721 Cn BT">Fornavn : </font> </TD> <TD> <input type=text size=40 maxlength=45 name=Fornavn>* </TD> </tr> <tr> <TD align="right"> <font size="3" face="swis721 Cn BT">Efternavn : </font> </TD> <TD> <input type=text size=40 maxlength=45 name=Efternavn>* </TD> </tr> <tr> <TD align="right"> <font size="3" face="swis721 Cn BT">Cpr. nr. : </font> </TD> <TD> <input type=text size=40 maxlength=45 name=CPR>* </TD> </tr> <tr> <TD align="right"> <font size="3" face="swis721 Cn BT">Adresse : </font> </TD> <TD> <input type=text size=40 maxlength=45 name=Adresse> </TD> </tr> <tr> <TD align="right"> <font size="3" face="swis721 Cn BT">Postnr. : </font> </TD> <TD> <input type=text size=4 maxlength=4 name=Postnr> </TD> </tr> <tr> <TD align="right"> <font size="3" face="swis721 Cn BT">By : </font> </TD> <TD> <input type=text size=40 maxlength=45 name=By> </TD> </tr> <tr> <TD align="right"> <font size="3" face="swis721 Cn BT">Telefon : </font> </TD> <TD> <input type=text size=8 maxlength=8 name=Telefon>* </TD> </tr> <tr> <TD align="right"> <font size="3" face="swis721 Cn BT">E-mail : </font> </TD> <TD> <input type=text size=40 maxlength=45 name=E_mail> </TD> </tr> </table> <table cellpadding=2 cellspacing=2> <tr> <TD> <font size="3" face="swis721 Cn BT">Jeg er ny patient på klinikken</font> <input type="checkbox" name="Jeg er ny patient " value="ok"> </TD> <TD> <font size="3" face="swis721 Cn BT">eller allerede patient på klinikken</font> <input type="checkbox" name="Jeg er ikke ny patient " value="ok"> </TD> </tr> <tr> <TD> <font size="3" face="swis721 Cn BT">Hvilken tid passer dig bedst:</font> </TD> <TD> </TD> </tr> <tr> <TD> <font size="3" face="swis721 Cn BT">Vælg ugedag:</font> </TD> <TD> <font size="3" face="swis721 Cn BT">Vælg tidspunkt:</font> </TD> </tr> <tr> <TD> <font size="3" face="swis721 Cn BT">Alle dage </font> <input type="checkbox" name="Alle dage " value="ok"> </TD> <TD> <font size="3" face="swis721 Cn BT">Hele dagen </font> <input type="checkbox" name="Hele dagen " value="ok"> </TD> </tr> <tr> <TD> <font size="3" face="swis721 Cn BT">Mandage </font> <input type="checkbox" name="Mandage " value="ok"> </TD> <TD> <font size="3" face="swis721 Cn BT">Formiddage </font> <input type="checkbox" name="Formiddage " value="ok"> </TD> </tr> <tr> <TD> <font size="3" face="swis721 Cn BT">Tirsdage <input type="checkbox" name="Tirsdage " value="ok"> </TD> <TD> <font size="3" face="swis721 Cn BT">8.00 - 9.30 </font> <input type="checkbox" name="Kl. 8.00-9.30 " value="ok"> </TD> </tr> <tr> <TD> <font size="3" face="swis721 Cn BT">Onsdage </font> <input type="checkbox" name="Onsdage " value="ok"> </TD> <TD> <font size="3" face="swis721 Cn BT">9.30 - 12.30</font> <input type="checkbox" name="Kl. 9.30-12.30 " value="ok"> </TD> </tr> <tr> <TD> <font size="3" face="swis721 Cn BT">Torsdage</font> <input type="checkbox" name="Torsdage" value="ok"> </TD> <TD> <font size="3" face="swis721 Cn BT">13.00 - 15.00 </font> <input type="checkbox" name="Kl 13.00-15.00 " value="ok"> </TD> </tr> <tr> <TD> <font size="3" face="swis721 Cn BT">Fredage </font> <input type="checkbox" name="Fredage" value="ok"> </TD> <TD> <font size="3" face="swis721 Cn BT">15.00 - 16.00</font> <input type="checkbox" name="Kl. 15-16 " value="ok"> </TD> </tr> <tr> <TD> </TD> <TD> <font size="3" face="swis721 Cn BT">16.00 - 17.00</font> <input type="checkbox" name="Kl. 16-17 " value="ok"> </TD> </tr> <tr> <TD > <font size="3" face="swis721 Cn BT">Hvis din tidsbestilling gælder andet end </font> </TD> <TD> </TD> </tr> <tr> <TD > <font size="3" face="swis721 Cn BT">almindeligt eftersyn og tandrensning </font> </TD> <TD> </TD> </tr> <tr> <TD > <font size="3" face="swis721 Cn BT">bedes bemærkningsfeltet udfyldt. :</font> </TD> <TD> </TD> </tr> <tr> <TD colspan=2 > <input type=text size=60 maxlength=85 name=Bemaerk> </TD> </tr> <tr> <TD> <font size="3" face="swis721 Cn BT">Tryk på</font> <input type=submit value="Send oplysningerne"> </TD> <TD> </TD> </tr> </table> <P><font size="3" face="swis721 Cn BT">TANDLÆGE JETTE STEPPUTAT/ VEDBÆK STATIONSVEJ 21 / 2950 VEDBÆK / TLF. 4589 1137 / JETTE@STEPPUTAT.DK</font></P> </FORM> </td> </tr> </table> </div> </body> </html>