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	<title>First United Methodist Church of Wichita Falls - WELCOME! &#187; Hospitals</title>
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	<link>http://fumcwf.org</link>
	<description>. . . a Downtown Tradition of Bringing Faith to Life in Service and Word!</description>
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		<title>Hospital Form</title>
		<link>http://fumcwf.org/archives/612</link>
		<comments>http://fumcwf.org/archives/612#comments</comments>
		<pubDate>Tue, 17 Feb 2009 12:44:57 +0000</pubDate>
		<dc:creator>tsims</dc:creator>
				<category><![CDATA[Hospitals]]></category>

		<guid isPermaLink="false">http://fumcwf.org/?p=612</guid>
		<description><![CDATA[Here you can share with us information about a current or upcoming hospital stay:




Name 




e-Mail 




Who will the patient be? 



Myself
A Loved One





Patient's Name (if [...]]]></description>
			<content:encoded><![CDATA[<p>Here you can share with us information about a current or upcoming hospital stay:</p>
<div id='formBuilderCSSIDHospital'>
<form class='formBuilderForm' id='formBuilderHospital' action='/archives/category/membership_care/hospitals/feed#formBuilderCSSIDHospital' method='post' onsubmit='return fb_disableForm(this);'><input type='hidden' name='formBuilderForm[FormBuilderID]' value='5' /><div id='formbuilder-page-1' title='formbuilder-page-1'>
<div class='formBuilderField single_line_text_box' id='formBuilderFieldName' title='You must enter your name.' ><a name='formBuilderFieldName'></a>
<span id='formBuilderErrorSpaceformBuilderFieldName'></span>
<div class='formBuilderLabelRequired'>Name </div>
<div class='formBuilderInput'><input type='text' name='formBuilderForm[Name]' value='' id='fieldformBuilderFieldName' onblur="fb_ajaxRequest('http://fumcwf.org/wp-content/plugins/formbuilder/php/formbuilder_parser.php', 'formid=5&amp;fieldid=22&amp;val='+document.getElementById('fieldformBuilderFieldName').value, 'formBuilderErrorSpaceformBuilderFieldName')"/></div>
</div>
<div class='formBuilderField single_line_text_box' id='formBuilderFieldEmail' title='You must enter your email address.' ><a name='formBuilderFieldEmail'></a>
<span id='formBuilderErrorSpaceformBuilderFieldEmail'></span>
<div class='formBuilderLabelRequired'>e-Mail </div>
<div class='formBuilderInput'><input type='text' name='formBuilderForm[Email]' value='' id='fieldformBuilderFieldEmail' onblur="fb_ajaxRequest('http://fumcwf.org/wp-content/plugins/formbuilder/php/formbuilder_parser.php', 'formid=5&amp;fieldid=23&amp;val='+document.getElementById('fieldformBuilderFieldEmail').value, 'formBuilderErrorSpaceformBuilderFieldEmail')"/></div>
</div>
<div class='formBuilderField selection_dropdown' id='formBuilderFieldpatient' title='Please let us know who will be in the hospital.' ><a name='formBuilderFieldpatient'></a>
<span id='formBuilderErrorSpaceformBuilderFieldpatient'></span>
<div class='formBuilderLabelRequired'>Who will the patient be? </div>
<div class='formBuilderSelect'>
<select name='formBuilderForm[patient]'>
<option value='0' selected = 'selected'></option>
<option value='1' >Myself</option>
<option value='2' >A Loved One</option>
</select>
</div>
</div>
<div class='formBuilderField single_line_text_box' id='formBuilderFieldpatient_name' title='' ><a name='formBuilderFieldpatient_name'></a>
<span id='formBuilderErrorSpaceformBuilderFieldpatient_name'></span>
<div class='formBuilderLabel'><b>Patient's Name (if different than yourself)</b> </div>
<div class='formBuilderInput'><input type='text' name='formBuilderForm[patient_name]' value='' id='fieldformBuilderFieldpatient_name' onblur="fb_ajaxRequest('http://fumcwf.org/wp-content/plugins/formbuilder/php/formbuilder_parser.php', 'formid=5&amp;fieldid=26&amp;val='+document.getElementById('fieldformBuilderFieldpatient_name').value, 'formBuilderErrorSpaceformBuilderFieldpatient_name')"/></div>
</div>
<div class='formBuilderField single_line_text_box' id='formBuilderFieldhospital' title='Please tell us which hospital the stay will be at.' ><a name='formBuilderFieldhospital'></a>
<span id='formBuilderErrorSpaceformBuilderFieldhospital'></span>
<div class='formBuilderLabelRequired'>What is the hospital name? </div>
<div class='formBuilderInput'><input type='text' name='formBuilderForm[hospital]' value='' id='fieldformBuilderFieldhospital' onblur="fb_ajaxRequest('http://fumcwf.org/wp-content/plugins/formbuilder/php/formbuilder_parser.php', 'formid=5&amp;fieldid=27&amp;val='+document.getElementById('fieldformBuilderFieldhospital').value, 'formBuilderErrorSpaceformBuilderFieldhospital')"/></div>
</div>
<div class='formBuilderField large_text_area' id='formBuilderFieldother_info' title='Please help us to know more about the situation.' ><a name='formBuilderFieldother_info'></a>
<span id='formBuilderErrorSpaceformBuilderFieldother_info'></span>
<div class='formBuilderLabelRequired'>Other Info (Dates, Times, Procedures) </div>
<div class='formBuilderLargeTextarea'><textarea name='formBuilderForm[other_info]' rows='10' cols='80' id='fieldformBuilderFieldother_info' onblur="fb_ajaxRequest('http://fumcwf.org/wp-content/plugins/formbuilder/php/formbuilder_parser.php', 'formid=5&amp;fieldid=24&amp;val='+document.getElementById('fieldformBuilderFieldother_info').value, 'formBuilderErrorSpaceformBuilderFieldother_info')" ></textarea></div>
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<div class='formBuilderField selection_dropdown' id='formBuilderFieldshare_info' title='Please select YES or NO.' ><a name='formBuilderFieldshare_info'></a>
<span id='formBuilderErrorSpaceformBuilderFieldshare_info'></span>
<div class='formBuilderLabelRequired'>May we share this info with the church? </div>
<div class='formBuilderSelect'>
<select name='formBuilderForm[share_info]'>
<option value='0' selected = 'selected'></option>
<option value='1' >YES</option>
<option value='2' >NO</option>
</select>
</div>
</div>
<div class='formBuilderField selection_dropdown' id='formBuilderFieldpastoral_visit' title='Please select YES or NO.' ><a name='formBuilderFieldpastoral_visit'></a>
<span id='formBuilderErrorSpaceformBuilderFieldpastoral_visit'></span>
<div class='formBuilderLabelRequired'>If possible, would you like a pastor to visit the patient? </div>
<div class='formBuilderSelect'>
<select name='formBuilderForm[pastoral_visit]'>
<option value='0' selected = 'selected'></option>
</select>
</div>
</div><input type='hidden' name='PAGE' value='http://fumcwf.org/archives/category/membership_care/hospitals/feed' />
<div class='formBuilderSubmit'><input type='submit' name='Submit' value='Send!' /></div>
</div>
</form></div>
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