{include_php file="shared_handle:contactForm"}

<h1 class="withBG">Contact Us</h1>

<strong>You can contact us by E-mail, phone, or U.S. mail. </strong><br><br>

<form name="contactForm" action="index.php" method="post">
<input type="hidden" name="pg" value="{$page.name}">
<input type="hidden" name="no_expire" value="true">

<table>
<tr>
	<td><span>Your Name:</span></td>
	<td><input type="text" name="mfName" value="{$smarty.request.mfName|stripslashes|htmlspecialchars}"></td>
</tr>
<tr>
	<td><span>Your E-mail Address:</span></td>
	<td><input type="text" name="mfEmail" value="{$smarty.request.mfEmail|stripslashes|htmlspecialchars}"></td>
</tr>
<tr>
	<td><span>Your Phone:</span></td>
	<td><input type="text" name="mfPhone" value="{$smarty.request.mfPhone|stripslashes|htmlspecialchars}"></td>
</tr>

<tr>
	<td><span>Subject:</span></td>
	<td><input type="text" name="mfSubject" value="{$smarty.request.mfSubject|stripslashes|htmlspecialchars}"></td>
</tr>
<tr>
	<td><span>Message Body:</span></td>
	<td><textarea cols="35" rows="6" name="mfMessage">{$smarty.request.mfMessage|stripslashes|htmlspecialchars}</textarea></td>
</tr>
<tr>
	<td><span>&nbsp;</span></td>
	<td><input type="submit" value="Send Now"></td>
</tr>
</table>
<div class="underline">&nbsp;</div>
<br />
<table>
<tr>
	<td><span>E-Mail:</span></td>
	<td><span><strong>Fill out the form above or email us at <br>{mailto address="contact@ehealthcompete.com" text="contact@ehealthcompete.com" encode="javascript"}</strong></span></td>
</tr>
<tr>
	<td><span>Phone:</span></td>
	<td><span><strong>801.602.9669</strong></span></td>
</tr>
<!--tr>
	<td><span>Fax:</span></td>
	<td><span><strong>1-801-555-5555 </strong></span></td>
</tr-->
<tr>
	<td valign="top" nowrap><span><br>U.S. Mail: &nbsp; &nbsp; </span></td>
	<td><span><strong><br>eHealthCompete, L.L.C. <br>
			2111 N. 120 W. #263<br>
			Provo, UT 84604</strong></span></td>
</tr>
</table>

</form>
