document.write("    <!-- Web Form Generator 2.0 -->    <center><form method=\"post\" action=\"http://www.aweber.com/scripts/addlead.pl\">    <input type=\"hidden\" name=\"meta_web_form_id\" value=\"707820654\">    <input type=\"hidden\" name=\"meta_split_id\" value=\"\">    <input type=\"hidden\" name=\"unit\" value=\"infrexplustrial\">    <input type=\"hidden\" name=\"redirect\" value=\"http://www.painreductiontherapy.com/index.php?/please-verify-your-email-infrex-free-trial.html\" id=\"redirect_2bfca4ad9e512222947b76649b26e688\">    <input type=\"hidden\" name=\"meta_redirect_onlist\" value=\"\">    <input type=\"hidden\" name=\"meta_adtracking\" value=\"\">    <input type=\"hidden\" name=\"meta_message\" value=\"1\">    <input type=\"hidden\" name=\"meta_required\" value=\"from\">    <input type=\"hidden\" name=\"meta_forward_vars\" value=\"0\">    <table>    <tr><td colspan=2><center><div><font color=\"#ff0000\"><strong>Yes, STOP MY PAIN PLEASE</strong></font><br></div></center></td></tr><tr><td>First Name:</td><td><input type=\"text\" name=\"name\" value=\"\" size=\"20\"></td></tr><tr><td>Email:</td><td><input type=\"text\" name=\"from\" value=\"\" size=\"20\"></td></tr><tr><td>Phone Number:</td><td><input type=\"text\" name=\"custom Phone Number\" value=\"\" size=\"20\"></td></tr>        <tr><td colspan=2><center><p><font size=\"4\"><strong>FREE</strong></font> <u><font color=\"#0000ff\"><strong>Infrex Plus Trial</strong></font></u></p><p> We will not sell, rent, distribute<br>in any way your information furnished.</p></center></td></tr>    <tr><td align=\"center\" colspan=\"2\"><input type=\"submit\" name=\"submit\" value=\"Get Me Started!\"></td></tr>    </table>    </form>        </center>");

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