

     <!-- SiteMaker 6.5 CMS (TM)
     Code created by Medseek, Inc. 2028 Village Lane, Solvang CA 93463.
     Phone 1-888 MEDSEEK. email info@medseek.com. http://www.medseek.com 
     (c) 1999-2006 Medseek, Inc. All rights reserved.-->
    








	

		
		
		
		
		
		
		
		
		
		
		
		
		
		

		
			
		
		 
		
		
		
		

		
		
		
		
		
		
		
		
		
		

		
		
		
		

		

		
		
		

			
				
			
		
		
		
		
		

		
		
		
		
		
		
		
			

		
		
		
		
				
		
		
		
				
		
			
		

		
		
		
		
		
		
	
		
			
			
			
		
		
		
	
		
			
			
		

		
		
		
		
			

		

		
		
		

			
				
			
		
		
		
		
		

		
		
		
		
		
		

		
					
						
		
		
				
		
		
		
		
		
				
		
		

		
		
		
		
		
		
		
		
			
			
				
			
		
		
		
		
		
			
			
		
		
		
		
		
			
			
		

		
		
		
			
			
		
		
		

		
			

			
		
		

		
		

		
				
		 
		
			
		
		
		

		
			
			
		
		
		
			

		

		
		
		
		

		
		

		
		
		
		
		
		
		
		
		
		

		
	

		
		
		
		
		
		
		
		
		
		
		
		
		
		

		
			
		
		 
		
		
		
		

		
		
		
		
		
		
		
		
		
		

		
		
		
		

		

		
		
		

			
				
			
		
		
		
		
		

		
		
		
		
		
		
		
			

		
		
		
		
				
		
		
		
				
		
			
		

		
		
		
		
		
		
	
		
			
			
			
		
		
		
	
		
			
			
		

		
		
		
		
			

		

		
		
		

			
				
			
		
		
		
		
		

		
		
		
		
		
		

		
					
						
		
		
				
		
		
		
		
		
				
		
		

		
		
		
		
		
		
		
		
			
			
				
			
		
		
		
		
		
			
			
		
		
		
		
		
			
			
		

		
		
		
			
			
		
		
		

		
			

			
		
		

		
		

		
				
		 
		
			
		
		
		

		
			
			
		
		
		
			

		

		
		
		
		

		
		

		
		
		
		
		
		
		
		
		
		

		
	

		
		
		
		
		
		
		
		
		
		
		
		
		
		

		
			
		
		 
		
		
		
		

		
		
		
		
		
		
		
		
		
		

		
		
		
		

		

		
		
		

			
				
			
		
		
		
		
		

		
		
		
		
		
		
		
			

		
		
		
		
				
		
		
		
				
		
			
		

		
		
		
		
		
		
	
		
			
			
			
		
		
		
	
		
			
			
		

		
		
		
		
			

		

		
		
		

			
				
			
		
		
		
		
		

		
		
		
		
		
		

		
					
						
		
		
				
		
		
		
		
		
				
		
		

		
		
		
		
		
		
		
		
			
			
				
			
		
		
		
		
		
			
			
		
		
		
		
		
			
			
		

		
		
		
			
			
		
		
		

		
			

			
		
		

		
		

		
				
		 
		
			
		
		
		

		
			
			
		
		
		
			

		

		
		
		
		

		
		

		
		
		
		
		
		
		
		
		
		

		
	

		
		
		
		
		
		
		
		
		
		
		
		
		
		

		
			
		
		 
		
		
		
		

		
		
		
		
		
		
		
		
		
		

		
		
		
		

		

		
		
		

			
				
			
		
		
		
		
		

		
		
		
		
		
		
		
			

		
		
		
		
				
		
		
		
				
		
			
		

		
		
		
		
		
		
	
		
			
			
			
		
		
		
	
		
			
			
		

		
		
		
		
			

		

		
		
		

			
				
			
		
		
		
		
		

		
		
		
		
		
		

		
					
						
		
		
				
		
		
		
		
		
				
		
		

		
		
		
		
		
		
		
		
			
			
				
			
		
		
		
		
		
			
			
		
		
		
		
		
			
			
		

		
		
		
			
			
		
		
		

		
			

			
		
		

		
		

		
				
		 
		
			
		
		
		

		
			
			
		
		
		
			

		

		
		
		
		

		
		

		
		
		
		
		
		
		
		
		
		

		
	

		
		
		
		
		
		
		
		
		
		
		
		
		
		

		
			
		
		 
		
		
		
		

		
		
		
		
		
		
		
		
		
		

		
		
		
		

		

		
		
		

			
				
			
		
		
		
		
		

		
		
		
		
		
		
		
			

		
		
		
		
				
		
		
		
				
		
			
		

		
		
		
		
		
		
	
		
			
			
			
		
		
		
	
		
			
			
		

		
		
		
		
			

		

		
		
		

			
				
			
		
		
		
		
		

		
		
		
		
		
		

		
					
						
		
		
				
		
		
		
		
		
				
		
		

		
		
		
		
		
		
		
		
			
			
				
			
		
		
		
		
		
			
			
		
		
		
		
		
			
			
		

		
		
		
			
			
		
		
		

		
			

			
		
		

		
		

		
				
		 
		
			
		
		
		

		
			
			
		
		
		
			

		

		
		
		
		

		
		

		
		
		
		
		
		
		
		
		
		

		
	
	
	
	
	
	
	
	
	
	

	
	
		
	
	
	<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN">
	<html>
	<head>
	<title>Contact Form | UCLA Center For Esophageal Disorders - Los Angeles, CA</title>
	<meta http-equiv="Content-Type" content="text/html; charset=UTF-8">
	
	<meta name="description" content="Contact the UCLA Center for Esophageal Disorders.">
	<meta name="keywords" content="contact ucla esophageal disorders center,contact esophageal center at ucla,ucla esophageal center contact">
	<style type="text/css">
		
		@import url(default.css);
		@import url("healthsystem.css");
	</style>
<script language="javascript" src="scripts/weather.js" type="text/javascript"></script>
	<script src="scripts/AC_ActiveX.js" type="text/javascript"></script> 
	<script src="scripts/AC_RunActiveContent.js" type="text/javascript"></script>
	<script type="text/JavaScript">
	<!--
	function MM_swapImgRestore() { //v3.0
		var i,x,a=document.MM_sr; for(i=0;a&&i<a.length&&(x=a[i])&&x.oSrc;i++) x.src=x.oSrc;
	}
	function MM_preloadImages() { //v3.0
		var d=document; if(d.images){ if(!d.MM_p) d.MM_p=new Array();
			var i,j=d.MM_p.length,a=MM_preloadImages.arguments; for(i=0; i<a.length; i++)
			if (a[i].indexOf("#")!=0){ d.MM_p[j]=new Image; d.MM_p[j++].src=a[i];}}
	}
	function MM_findObj(n, d) { //v4.01
		var p,i,x;  if(!d) d=document; if((p=n.indexOf("?"))>0&&parent.frames.length) {
			d=parent.frames[n.substring(p+1)].document; n=n.substring(0,p);}
		if(!(x=d[n])&&d.all) x=d.all[n]; for (i=0;!x&&i<d.forms.length;i++) x=d.forms[i][n];
		for(i=0;!x&&d.layers&&i<d.layers.length;i++) x=MM_findObj(n,d.layers[i].document);
		if(!x && d.getElementById) x=d.getElementById(n); return x;
	}	
	function MM_swapImage() { //v3.0
		var i,j=0,x,a=MM_swapImage.arguments; document.MM_sr=new Array; for(i=0;i<(a.length-2);i+=3)
		 if ((x=MM_findObj(a[i]))!=null){document.MM_sr[j++]=x; if(!x.oSrc) x.oSrc=x.src; x.src=a[i+2];}
	}
	//
	function addEvent(obj, evType, fn){
		if (obj.addEventListener){
			obj.addEventListener(evType, fn, false);
			return true;
		} else if (obj.attachEvent){
			var r = obj.attachEvent("on"+evType, fn);
			return r;
		} else {
			return false;
		}
	}
	function DHTMLIframeHeight(){
		var z	=	new RegExp('lryParentmain[0-9]+');
		var x	=	new RegExp('Framelyr[0-9]+');
		var h = 0;
		var	a	=	new Array();
		var	u	=	0;
		for(y = 0; w = document.getElementsByTagName("div")[y]; y++){
			try{
				if(w.id.match(z)){
					var c	=	0;
					var d = 0;
					var t = 0;
					var e	=	document.getElementById(w.id).getElementsByTagName("iframe");
					for(i	=	0; i < e.length; i++){
						if(e[i].id.match(x)){
							c++;
							u=0;
							t=0;
							a[c] = e[i].id.substring(8,(e[i].id.length));
							l = document.getElementById('lyr'+a[c]).getElementsByTagName("a");
							e[i].style.height = "0px";
							for(h=0; classname = l[h].className; h++){
								try{
									if(classname == "clSubb1"){
										d++;
										u = 0;
										u = l[h].innerHTML.length;
										u = Math.floor(u / 16);
										if(u <= 0){u = 1;}
										u = u * 23;
										t = t + u;
										e[i].style.height = t;
									}
								}
								catch(error2) {
									//
								}
								
							}
						}
					}
				}
			}
			catch(error) {
				//
			}
		}
	}
	if(navigator.userAgent.indexOf('MSIE 6') > 0){
		addEvent(window, 'load', DHTMLIframeHeight);
	}
	//
	//-->
	</script>
	
				
<script type="text/javascript">
//<!--
var ns4 = (document.layers);
var ie  = (document.all);
var ie4 = (ie && !document.getElementById);
var ie5 = (ie && document.getElementById);
var ns6 = (!ie && document.getElementById);

var aryMoused = new Array();
var aryLayerMoused = new Array();
var aryMoImages = new Array();
var imageList = new Array();
var runMouseOvers = true;
var TimerID = null;
var iLimit = 25;
var itmp = 0;

var nbTime = 100;
var nbTimes = 2;
var nbThisLoc = 325;
var aryLayerNames = new Array();
var aryNavBarLayerInfo = new Array();
var aryNavBarLayers = new Array();

var registeredObjects = new Array();
var viz = "hide";

function MOImage() {
	var arg = MOImage.arguments;
	this.ptrImage = BillzNavBarMM_findObj(arg[0]);
	this.imageMO = new Image();
	this.imageMO.src = arg[1];
	this.HTMLname = arg[0];
	this.Moused = false;
	this.OriginalSrc = '';
	return true;
}

function BillzImagePreload() {
	// 0) html image name 1) mo image src 2)image Name for rollover key (rollover may have multiple mos for one html Image) 
	var arg = BillzImagePreload.arguments;
	nbImagePreload(arg[0], arg[1], arg[2]);
}

function nbImagePreload(img_name, mo_img_src, rollover_key_img_name) {
	var imageKey = (rollover_key_img_name.length > 0) ? rollover_key_img_name : img_name;
	imageList[imageList.length] = imageKey;
	if (!(aryMoImages[imageKey])) aryMoImages[imageKey] = new MOImage(img_name, mo_img_src);
}

function BillzMouseover() {
	var arg = null;
	if (runMouseOvers) {		
		arg = BillzMouseover.arguments; //args 0)ImageName 1)OriginalSrc 2)array index (caller imagename)		
		nbMouseover(arg[0], arg[1], arg[2]);
	}
	return true;
}
// args 1) ImageName 2) OriginalSrc 3) array index (caller imagename)
function nbMouseover(img_name, orig_src, img_key) {
	var imageKey = null;
	var o = null;
	if (runMouseOvers) 
	{				
		imageKey = (img_key.length > 0) ? img_key : img_name;
		if (!(aryMoImages[imageKey].ptrImage)) aryMoImages[imageKey].ptrImage = BillzNavBarMM_findObj(img_name);		
		if (aryMoImages[imageKey] && (o = aryMoImages[imageKey].ptrImage)) {
			aryMoImages[imageKey].OriginalSrc = orig_src;
			aryMoImages[imageKey].Moused = true;
			o.src = aryMoImages[imageKey].imageMO.src;
		}
	}
	return true;
}

var NavBarTempOnload = null;
if (window.onload && window.onload != null) NavBarTempOnload = window.onload;

function FullyLoaded() {
	if (NavBarTempOnload != null) NavBarTempOnload();
	runMouseOvers = true;
	return true;
}

function BillzMouseOutTimer() {
	return nbMouseOutTimer();
}

function nbMouseOutTimer() {
	if (TimerID) clearTimeout(TimerID);
	TimerID = setTimeout("nbLayerRestore()",5000);
	return true;
}

function RestoreAll() {
	nbMouseoverRestore();
	nbLayerRestore();
	return true;
}

function BillzMouseoverRestore() {
	return nbMouseoverRestore();
}

function nbMouseoverRestore() {
	var i = 0;
	var o = null;
	if (runMouseOvers) {
		for (i = 0; i < imageList.length; i++) {
			if (aryMoImages[imageList[i]].Moused && (o = aryMoImages[imageList[i]].ptrImage)) {
				o.src = aryMoImages[imageList[i]].OriginalSrc;
				aryMoImages[imageList[i]].Moused = false;
			}
		}
	}
	return true;
}

function BillzLayerRestore() {
	return nbLayerRestore();
}

function nbLayerRestore() {
	var i = 0;
	for (i = 0; i < aryLayerNames.length; i++) {
		if (!aryNavBarLayerInfo[aryLayerNames[i]].isDefault) BillzNavBarRestoreLayers(aryLayerNames[i]);	
	}
	return true;
}

function BillzArrayPushUnique(aryArray, varNewElement) { //only pushes if unique value
	var pushIt = true;
	var i = 0;
	for (i = 0; i < aryArray.length && pushIt; i++) {
		pushIt = (varNewElement != aryArray[i]);
	}
	if (pushIt) BillzArrayPush(aryArray, varNewElement);
	return pushIt;
}

function BillzArrayPush(aryArray, varNewElement) { //Implement Array Push 'cause IE cant handle it
	aryArray[aryArray.length] = varNewElement;
	return true;
}
function BillzArrayPop(aryArray) { //Implement Array Pop 'cause IE cant handle it before 5.5
	var varItemToPop = null;
	if (aryArray[aryArray.length - 1]) {
		varItemToPop = aryArray[aryArray.length - 1];
		aryArray[aryArray.length] = null;
	}
	return varItemToPop;
}

function getDivRef(id) {
	var divref;
	if(ns4) divref = document.layers[id];
	else if(ie4) divref = document.all[id];
	else if(ie5 || ns6) divref = document.getElementById(id);	
	return divref;
}

//v3.0 name changed to avoid clash with possible other JS in content, this function complements of MM Dreamweaver
function NavBarSwapRollover(swapimage,defaultimage,imageID) {
	if(imageID.length > 0 && document.getElementById(imageID))
	{
		if(swapimage.length > 0) 
			document.getElementById(imageID).src = "images/" + swapimage;
		else
			document.getElementById(imageID).src = "images/" + defaultimage;		
	}
}
function BillzNavBarMM_findObj(n, d) {
	var p,i,x;
	if (ns6) x = document.getElementById(n);
	else {		
		if (registeredObjects[n]) return registeredObjects[n];
		if (!(d)) d = document;
		try {
			p = n.indexOf("?");
		}
		catch(e) {
			p = 0;
		}
		if (p > 0 && parent.frames.length) {
			d = parent.frames[n.substring(p+1)].document;
			n = n.substring(0,p);
		}
		if (!(x = d[n]) && d.all) x = d.all[n];	
		for (i = 0; !x && i < d.forms.length; i++) {
			x = d.forms[i][n];
		}
		for (i=0; !x && d.layers && i < d.layers.length; i++) {
			if (d.layers[i].id.indexOf("external_") == -1) x = BillzNavBarMM_findObj(n, d.layers[i].document);	
		}
		registeredObjects[n] = x;
	}				
	return x;
}

function BillzArrayContains() {
	var arg = BillzArrayContains.arguments;
	var foundit = false;
	var i = 0;
	for (i = 0; i < arg[0].length && !foundit; i++) {
		foundit = (arg[1] == arg[0][i]);
	}
	return foundit;
}

function NavBarRegisterLayer() {
	var arg = NavBarRegisterLayer.arguments;
	var n = arg[0];
	var d = arg[1];
	var mo = false;
	var o = null;
	if (arg[2] && arg[2] == 'MOutLayer') mo = true;
	else mo = false;
	
	if (!(BillzArrayContains(aryLayerNames, n))) {
		if (o = BillzNavBarMM_findObj(n)) {
			aryNavBarLayers[n] = o;
			BillzArrayPushUnique(aryLayerNames, n);
			aryNavBarLayerInfo[n] = new NavBarLayer(n, d, mo);
		}
	}
	return true;
}

function BillzNavBarMM_showHideLayers() {
	//v3.0 name changed, this function complements of MM Dreamweaver with customizations by Bill Heller
	var i = 0;
	var x = "";
	var obj = null;
	var v = null;
	var p = null;
	var args = BillzNavBarMM_showHideLayers.arguments;
	
	if (args[args.length - 1] != "menu") nbMouseOutTimer();
	for (i = 0; i < (args.length - 2); i += 3) {
		if (!aryNavBarLayers[args[i]]) {
			x = (args[i + 2] == 'show') ? 'hide' : 'show';
			NavBarRegisterLayer(args[i], x);
		}
		if ((obj = aryNavBarLayers[args[i]]) != null) {
			v = args[i + 2];
			aryNavBarLayerInfo[args[i]].isDefault = false;
			if (args[args.length - 1] == "restore") v = (v == 'show') ? 'hide' : 'show';
			
			if (obj.style) obj.style.visibility = (v == 'show') ? 'visible' : ((v == 'hide') ? 'hidden' : v);
			else obj.visibility = v;
		}
	}
	return true;
}

function BillzNavBarRestoreLayers() {
	var i = 0;
	var x = "";
	var obj = null;
	var v = null;
	var p = null;
	var args = BillzNavBarRestoreLayers.arguments;
	for (i = 0; i < (args.length); i++) {
		if (obj = aryNavBarLayers[args[i]]) {
			v = aryNavBarLayerInfo[args[i]].defaultVisibility;
			if (obj.style) {
				obj = obj.style;
				v = (v == 'show' ) ? 'visible' : ((v == 'hide') ? 'hidden' : v);
			}
			obj.visibility = v;
			if (!aryNavBarLayerInfo[args[i]].MOutLayer) aryNavBarLayerInfo[args[i]].isDefault = true;			
		}
	}
	return true;
}

function NavBarLayer() {
	var arg = NavBarLayer.arguments;
	this.defaultVisibility = arg[1];
	this.isDefault = true;
	this.MOutLayer = arg[2];
	return true;
}

function BillzNavMove() {
	return nbNavMove();
}

function nbNavMove() {
	var thisl = null;
	var otherl = null;
	if (thisl = BillzNavBarMM_findObj("nbScrollLayer")) {
		if (thisl.style) {
			thisl = thisl.style;
			viz = "hidden";
		} 
		thisl.top = nbThisLoc -= 3;
		if (nbThisLoc < -750) {
			nbThisLoc = 325;
			nbTimes--;
		}
	}
	if (nbTimes <= 0) {
		otherl = BillzNavBarMM_findObj("BillzLayer");
		otherl.visibility = viz;
	} else {
		setTimeout("nbNavMove()", nbTime);
	}	
	return true;
}

function NavBar_openadmin() {
	window.open('admin/','SiteAdmin','height=screen.availheight,width=screen.availwidth,scrollbars=1,toolbar=0,directories=0,status=0,menubar=0,resizable=1');
	return true;
}

window.onload = FullyLoaded;
//-->
</script>
					
<script type="text/javascript">
//<!--
function NavBar_setCookie(cookievalue,navVersion,linkID) 
{	
	var cookiename = "SLIDINGTABLE_NAVBAR" + navVersion;
	var cookieVersionname = "SLIDINGTBL_NAVBAR_VERSION";
	var cookieClear = "SLIDINGTBL_NAVBAR_CLEARCOOKIES";	
	document.cookie = cookieClear.toUpperCase() + "=false";
	if(cookievalue.length > 0)
		document.cookie = cookiename.toUpperCase() + "=" + escape(cookievalue);
	if(navVersion.length > 0)	
		document.cookie = cookieVersionname.toUpperCase() + "=" + navVersion;	
	if(linkID.length > 0)
		NavBar_setPLinkIDCookie(linkID,navVersion);		
}
function NavBar_setoLevelIDCookie(cookievalue,linkID,navVersion) 
{
	var name = "SLIDINGTBL_NAVBAR_OLEVELID";		
	if(cookievalue.length > 0)
		document.cookie = name.toUpperCase() + "=" + escape(cookievalue);	
	if(linkID.length > 0)
		NavBar_setPLinkIDCookie(linkID,navVersion);	
	if(navVersion.length > 0)	
		document.cookie = "SLIDINGTBL_NAVBAR_VERSION=" + navVersion;		
}
function NavBar_setPLinkIDCookie(linkID,navVersion)
{	
	document.cookie = "SLIDINGTBL_NAVBAR_PLINKID=" + linkID;	
	if(navVersion.length > 0)	
		document.cookie = "SLIDINGTBL_NAVBAR_VERSION=" + navVersion;
}
function NavBar_deleteCookie() 
{
	// first we'll split this cookie up into name/value pairs
	// note: document.cookie only returns name=value, not the other components
	var check_name = "SLIDINGTABLE_NAVBAR";	
	var a_all_cookies = document.cookie.split( ';' );
	var a_temp_cookie = '';
	var cookie_name = '';
	var cookie_value = '';
	var b_cookie_found = false; // set boolean t/f default f	

	document.cookie = "SLIDINGTBL_NAVBAR_VERSION=0";	
	document.cookie = "SLIDINGTBL_NAVBAR_OLEVELID=";	
	for (i = 0; i < a_all_cookies.length; i++)
	{		
		a_temp_cookie = a_all_cookies[i].split( '=' );			
		cookie_name = a_temp_cookie[0].replace(/^\s+|\s+$/g, '');
		
		//expire all cookies for every slidingTable_navbar intances.			
		if (cookie_name.toUpperCase().indexOf(check_name) == 0)		
			document.cookie = cookie_name.toUpperCase() + "=";			 	
	}	
}
		
//-->
</script>
			
	    <style type="text/css">
	    <!--
	    @import url("module.css");
	    -->
	    </style>
	
				
<script type="text/javascript">
//<!--
				
nbImagePreload('footer_ucla_2_1','images/footer_ucla_on.gif', '');
nbImagePreload('footer_wheelchair_2_5','images/footer_wheelchair_on.gif', '');

//-->
</script>
<script type="text/javascript">
//<!--
function NavBar_setCookie(cookievalue,navVersion,linkID) 
{	
	var cookiename = "SLIDINGTABLE_NAVBAR" + navVersion;
	var cookieVersionname = "SLIDINGTBL_NAVBAR_VERSION";
	var cookieClear = "SLIDINGTBL_NAVBAR_CLEARCOOKIES";	
	document.cookie = cookieClear.toUpperCase() + "=false";
	if(cookievalue.length > 0)
		document.cookie = cookiename.toUpperCase() + "=" + escape(cookievalue);
	if(navVersion.length > 0)	
		document.cookie = cookieVersionname.toUpperCase() + "=" + navVersion;	
	if(linkID.length > 0)
		NavBar_setPLinkIDCookie(linkID,navVersion);		
}
function NavBar_setoLevelIDCookie(cookievalue,linkID,navVersion) 
{
	var name = "SLIDINGTBL_NAVBAR_OLEVELID";		
	if(cookievalue.length > 0)
		document.cookie = name.toUpperCase() + "=" + escape(cookievalue);	
	if(linkID.length > 0)
		NavBar_setPLinkIDCookie(linkID,navVersion);	
	if(navVersion.length > 0)	
		document.cookie = "SLIDINGTBL_NAVBAR_VERSION=" + navVersion;		
}
function NavBar_setPLinkIDCookie(linkID,navVersion)
{	
	document.cookie = "SLIDINGTBL_NAVBAR_PLINKID=" + linkID;	
	if(navVersion.length > 0)	
		document.cookie = "SLIDINGTBL_NAVBAR_VERSION=" + navVersion;
}
function NavBar_deleteCookie() 
{
	// first we'll split this cookie up into name/value pairs
	// note: document.cookie only returns name=value, not the other components
	var check_name = "SLIDINGTABLE_NAVBAR";	
	var a_all_cookies = document.cookie.split( ';' );
	var a_temp_cookie = '';
	var cookie_name = '';
	var cookie_value = '';
	var b_cookie_found = false; // set boolean t/f default f	

	document.cookie = "SLIDINGTBL_NAVBAR_VERSION=0";	
	document.cookie = "SLIDINGTBL_NAVBAR_OLEVELID=";	
	for (i = 0; i < a_all_cookies.length; i++)
	{		
		a_temp_cookie = a_all_cookies[i].split( '=' );			
		cookie_name = a_temp_cookie[0].replace(/^\s+|\s+$/g, '');
		
		//expire all cookies for every slidingTable_navbar intances.			
		if (cookie_name.toUpperCase().indexOf(check_name) == 0)		
			document.cookie = cookie_name.toUpperCase() + "=";			 	
	}	
}
		
//-->
</script>
			</head>
	
		
	
	
	
	
	
		
	



<style type="text/css">
#lryParentmain56 {
	display:none;
	visibility:hidden;
}
</style>
<body style="margin:0px; background-color:#7082a6;" class="body">
<table align="center" width="90%" bgcolor="#ffffff" border="0" cellpadding="0" cellspacing="0">
	<tr bgcolor="#e5ebeb">
		<td width="100%" height="28" valign="middle" style="border-bottom:1px dashed #999999;">
			<table width="100%" border="0" cellpadding="0" cellspacing="0">
				<tr>
					<td width="33%" height="28" valign="middle" style="padding-left:20px;font-size:10px;">Sun Nov 22, 2009</td>					<td width="33%" align="center" valign="middle">
						
	<!-- Begin NavBar Output  -  Version:  v0.79a 09/30/2006  -->
	
		<!-- Begin NavBar Bar #1 Content Output... -->
		<table  border="0" cellspacing="0" cellpadding="0" onclick="NavBar_deleteCookie();">
	<tr class="navbarnum1">
		<td class="navbarnum1" valign="top" align="left" title=""><a href="http://www.directory.ucla.edu"  target="_blank" onClick="NavBar_setPLinkIDCookie('10','');" class="navbarnum1">Directory</a></td>
		<td class="navbarnum1" valign="top" align="left" title=""><img src='images/topnav_btwn.gif' alt=""></td>
		<td class="navbarnum1" valign="top" align="left" title=""><a href="http://uclahealth.org/body.cfm?id=289"  target="_blank" onClick="NavBar_setPLinkIDCookie('9','');" class="navbarnum1">Maps</a></td>
		<td class="navbarnum1" valign="top" align="left" title=""><img src='images/topnav_btwn.gif' alt=""></td>
		<td class="navbarnum1" valign="top" align="left" title=""><a href="http://www.uclahealth.org/body.cfm?id=173"  target="_blank" onClick="NavBar_setPLinkIDCookie('8','');" class="navbarnum1">Calendar</a></td>
		<td class="navbarnum1" valign="top" align="left" title=""><img src='images/topnav_btwn.gif' alt=""></td>
		<td class="navbarnum1" valign="top" align="left" title=""><a href="http://www.uclahealth.org/body.cfm?id=46"  target="_blank" onClick="NavBar_setPLinkIDCookie('7','');" class="navbarnum1">News</a></td>
	</tr>
</table>
	
		<!-- End NavBar Output -->
	 

					</td>
					<td align="right" valign="middle">


	<style name="text/css" class="search">		
		td.search {background-color: clear.gif; background-image: URL(images/clear.gif); font-family: verdana,arial; font-weight: bold; font-size: 10px; font-color: 666666;}
				
	</style>

		<table border="0" cellpadding="0" cellspacing="0" background="" align= "right" class="search">		
		<form action="body.cfm?id=17" method="POST">		
		<input type="hidden" name="action" value="list">	
		<input type="hidden" name="search_areas_id" value="">	
		<input type="hidden" name="includewhat" value="">
			
			<tr class="search">							
				
					<td class="search">Search:&nbsp;&nbsp;</td>
				
				
					<td class="search"><input type="text" name="keywords" size="24" value="Search" style="background-color: FFFFFF; border-style: solid; border-color: a5acb2; border-width: 1px; font-size: 10px; padding-left:4px;"></td>
							
				
					<td class="search"><input type="IMAGE" src="images/go_button.gif" border="0" width="26" height="21" style="border:0px;"></td>
				
			</tr>
		</form>
		</table>
	 
</td>
				</tr>
			</table>
		</td>
	</tr>
	<tr>
		<td height="51" valign="top" style="background-image: url(images/logo_area_tile.gif); background-repeat: repeat-x; background-position: top left;">
			<table height="51" width="100%" border="0" cellpadding="0" cellspacing="0">
				<tr>
					<td width="1%" valign="middle"><img src="images/site/logo_top.gif" alt="UCLA Health System" border="0" hspace="18"></td>
					<td valign="bottom" width="1%" align="right" nowrap><a href="http://dgsom.healthsciences.ucla.edu" onMouseOut="MM_swapImgRestore()" onMouseOver="MM_swapImage('Research','','images/btn_schoolmed_on.gif',1)"><img src="images/btn_schoolmed.gif" alt="Research and Education: David Geffen School of Medicine at UCLA" name="Research" border="0"></a><a href="http://www.uclahealth.org" onMouseOut="MM_swapImgRestore()" onMouseOver="MM_swapImage('Patient Care','','images/btn_healthsystem_white_on.gif',1)"><img name="Patient Care" border="0" src="images/btn_healthsystem_white.gif" alt="Patient Care: UCLA Health System"></a></td>
				</tr>
			</table>
		</td>
	</tr>
	<tr> 
		<td align="center" valign="middle" style="border:2px solid #ffffff; background-color:#efc932;"><a href="default.cfm"><img src="images/site/logo_bar.gif" border="0" alt="UCLA Center for Esophageal Disorders"></a></td>
	</tr>
    <tr> 
		<td width="100%" style="vertical-align:middle; background-color:#fff;vertical-align:top;border-top:1px solid #aab6c8;">
			<table width="100%" border="0" cellpadding="0" cellspacing="0">
				<tr valign="top">
					<td valign="top" width="186" style="border-right:1px solid #aab6c8; padding-top:6px;">
						<div style="line-height:1px; margin:1px; width:186px;"></div>
						
						
						
						
						
							
								
							
							
								
									
								
							
							
							
						
						
						

<script type="text/javascript">
<!--
				
//Begin: Graphic Mouseover functions
function slidingTbl_preloadImages()
{
var d=document;
	if(d.images)
{
	if(!d.slidingTbl_p)
		d.slidingTbl_p=new Array();		
}
   var i,j=d.slidingTbl_p.length,a=slidingTbl_preloadImages.arguments;
for(i=0; i<a.length; i++)
{
  		if (a[i].indexOf("#")!=0)
	{
		d.slidingTbl_p[j]=new Image;
		d.slidingTbl_p[j++].src=a[i];
	}
}
}
function slidingTbl_swapImgRestore()
{
var i,x,a=document.slidingTbl_sr;
for(i=0; a && i<a.length && (x=a[i]) && x.oSrc; i++)
{
	x.src = x.oSrc;
}
}
function slidingTbl_findObj(n, d)
{
var p,i,x;
if(!d) d = document;
p = n.indexOf("?");	
x = d[n];
if(p > 0 && parent.frames.length)	
{
 		d = parent.frames[n.substring(p+1)].document; 
	n = n.substring(0,p);	
}	
if(!(x) && d.all) x = d.all[n];
for (i=0;!x && i < d.forms.length;i++)
{
	x = d.forms[i][n];
}
for(i=0;!x && d.layers && i<d.layers.length;i++)
{
	x = slidingTbl_findObj(n,d.layers[i].document);
}
 if(!x && d.getElementById) x = d.getElementById(n); 
 return x;
}
function slidingTbl_swapImage()
{
var i,j=0,x,a=slidingTbl_swapImage.arguments;
document.slidingTbl_sr = new Array;
for(i=0;i<(a.length-2);i+=3)
{		
	x = slidingTbl_findObj(a[i]);			
   	if (x != null)
   	{
		document.slidingTbl_sr[j++] = x;			
		if(!x.oSrc) x.oSrc = x.src;			
		x.src = a[i+2];			
	}
}
}
//End: Graphic Mouseover functions
							
function slidingTbl_SetCookie1(cookievalue) 
{		
document.cookie = "SLIDINGTABLE_NAVBAR1=" + escape(cookievalue);	
document.cookie = "SLIDINGTBL_NAVBAR_VERSION=1";
document.cookie = "SLIDINGTBL_NAVBAR_OLEVELID=";
}
function slidingTbl_SetoLevelIDCookie1(cookievalue)
{
document.cookie = "SLIDINGTBL_NAVBAR_OLEVELID=" + escape(cookievalue);	
document.cookie = "SLIDINGTBL_NAVBAR_VERSION=1";
document.cookie = "SLIDINGTABLE_NAVBAR1=";
}
function slidingTbl_ClearCookie1() 
{			
var check_name = "SLIDINGTABLE_NAVBAR";
var a_all_cookies = document.cookie.split( ';' );
var a_temp_cookie = '';
var cookie_name = '';
for (i = 0; i < a_all_cookies.length; i++)
{		
	a_temp_cookie = a_all_cookies[i].split( '=' );		
	cookie_name = a_temp_cookie[0].replace(/^\s+|\s+$/g, '');		
	
	//expire all cookies for every slidingTable_navbar intances.
	if (cookie_name.toUpperCase().indexOf(check_name) == 0) 	
		document.cookie = cookie_name.toUpperCase() + "=";					 	
}			
}
var SlidingTableTempOnload1 = null;
if(window.onload && window.onload != null)
{
SlidingTableTempOnload1 = window.onload;
}
function initsliding1()
{
if(SlidingTableTempOnload1 != null)	
	SlidingTableTempOnload1();

document.cookie = "SLIDINGTBL_NAVBAR_VERSION=";
slidingTbl_ClearCookie1();
slidingTbl_preloadImages();			
return true;
}

window.onload = initsliding1;
//-->
</script>
<table class="leftnav" cellspacing="0" onclick="JavaScript: document.cookie='SLIDINGTBL_NAVBAR_VERSION=1';">
	<tr class="leftnav" id="pLinkTR_26_1">
		<td class="leftnav" id="pLinkTD_26_1" onclick="slidingTbl_SetoLevelIDCookie1('26^26');"><a href="default.cfm" class="leftnav">Home</a></td>
	</tr>
	<tr class="leftnav" id="pBetweenTR_26_1">
		<td class="leftnav" id="pBetweenTD_26_1"><img class='leftnav' src='images/leftnavbreak.gif'></td>
	</tr>
	<tr class="leftnav" id="pLinkTR_19_1">
		<td class="leftnav" id="pLinkTD_19_1" onclick="slidingTbl_SetCookie1('19^19');"><a href="body.cfm?id=19" class="leftnav">About Us</a></td>
	</tr>
	<tr class="leftnav" id="pBetweenTR_19_1">
		<td class="leftnav" id="pBetweenTD_19_1"><img class='leftnav' src='images/leftnavbreak.gif'></td>
	</tr>
	<tr class="leftnav" id="pLinkTR_35_1">
		<td class="leftnav" id="pLinkTD_35_1" onclick="slidingTbl_SetCookie1('35^35');"><a href="body.cfm?id=35" class="leftnav">Our Expert Team</a></td>
	</tr>
	<tr class="leftnav" id="pBetweenTR_35_1">
		<td class="leftnav" id="pBetweenTD_35_1"><img class='leftnav' src='images/leftnavbreak.gif'></td>
	</tr>
	<tr class="leftnav" id="pLinkTR_58_1">
		<td class="leftnav" id="pLinkTD_58_1" onclick="slidingTbl_SetCookie1('58^58');"><a href="body.cfm?id=58" class="leftnav">Preparing for your visit</a></td>
	</tr>
	<tr class="leftnav" id="pBetweenTR_58_1">
		<td class="leftnav" id="pBetweenTD_58_1"><img class='leftnav' src='images/leftnavbreak.gif'></td>
	</tr>
	<tr class="leftnav" id="pLinkTR_44_1">
		<td class="leftnav" id="pLinkTD_44_1" onclick="slidingTbl_SetCookie1('44^44');"><a href="body.cfm?id=44" class="leftnav">Preparing for Surgery</a></td>
	</tr>
	<tr class="leftnav" id="pBetweenTR_44_1">
		<td class="leftnav" id="pBetweenTD_44_1"><img class='leftnav' src='images/leftnavbreak.gif'></td>
	</tr>
	<tr class="leftnav" id="pLinkTR_27_1">
		<td class="leftnav" id="pLinkTD_27_1" onclick="slidingTbl_SetCookie1('27^27');"><a href="body.cfm?id=27" class="leftnav">Conditions and Treatments</a></td>
	</tr>
	<tr class="leftnav" id="pBetweenTR_27_1">
		<td class="leftnav" id="pBetweenTD_27_1"><img class='leftnav' src='images/leftnavbreak.gif'></td>
	</tr>
	<tr class="leftnav" id="pLinkTR_39_1">
		<td class="leftnav" id="pLinkTD_39_1" onclick="slidingTbl_SetCookie1('39^39');"><a href="body.cfm?id=39" class="leftnav">Patient Stories</a></td>
	</tr>
	<tr class="leftnav" id="pBetweenTR_39_1">
		<td class="leftnav" id="pBetweenTD_39_1"><img class='leftnav' src='images/leftnavbreak.gif'></td>
	</tr>
	<tr class="leftnav" id="pLinkTR_20_1">
		<td class="leftnav" id="pLinkTD_20_1" onclick="slidingTbl_SetCookie1('20^20');"><a href="body.cfm?id=20" class="leftnav">Spotlight</a></td>
	</tr>
	<tr class="leftnav" id="pBetweenTR_20_1">
		<td class="leftnav" id="pBetweenTD_20_1"><img class='leftnav' src='images/leftnavbreak.gif'></td>
	</tr>
	<tr class="leftnav" id="pLinkTR_22_1">
		<td class="leftnav" id="pLinkTD_22_1" onclick="slidingTbl_SetCookie1('22^22');"><a href="body.cfm?id=22" class="leftnav">Clinical Trials and Research</a></td>
	</tr>
	<tr class="leftnav" id="pBetweenTR_22_1">
		<td class="leftnav" id="pBetweenTD_22_1"><img class='leftnav' src='images/leftnavbreak.gif'></td>
	</tr>
	<tr class="leftnav" id="pLinkTR_54_1">
		<td class="leftnav" id="pLinkTD_54_1" onclick="slidingTbl_SetCookie1('54^54');"><a href="body.cfm?id=54" class="leftnav">Contact Us</a></td>
	</tr>
	<tr class="leftnav" id="pBetweenTR_54_1">
		<td class="leftnav" id="pBetweenTD_54_1"><img class='leftnav' src='images/leftnavbreak.gif'></td>
	</tr>
	<tr class="leftnav" id="pLinkTR_23_1">
		<td class="leftnav" id="pLinkTD_23_1" onclick="slidingTbl_SetCookie1('23^23');"><a href="body.cfm?id=23" class="leftnav">Medical Terms</a></td>
	</tr>
	<tr class="leftnav" id="pBetweenTR_23_1">
		<td class="leftnav" id="pBetweenTD_23_1"><img class='leftnav' src='images/leftnavbreak.gif'></td>
	</tr>
	<tr class="leftnav" id="pLinkTR_25_1">
		<td class="leftnav" id="pLinkTD_25_1" onclick="slidingTbl_SetCookie1('25^25');"><a href="body.cfm?id=25" class="leftnav">Giving / Donations</a></td>
	</tr>
	<tr class="leftnav" id="pBetweenTR_25_1">
		<td class="leftnav" id="pBetweenTD_25_1"><img class='leftnav' src='images/leftnavbreak.gif'></td>
	</tr>
	<tr class="leftnav" id="pLinkTR_43_1">
		<td class="leftnav" id="pLinkTD_43_1" onclick="slidingTbl_SetCookie1('43^43');"><a href="body.cfm?id=43" class="leftnav">Esophageal News</a></td>
	</tr>
</table> 

						
						<br>
						<div style="text-align:center; padding-top:22px;"> 
</div>
						<br>
						<br>
						
					</td>
					<td>						
						
						<div style="line-height:1px; margin:0px; height:1px; width:400px;">&nbsp;</div>
						<table width="100%" border="0" cellpadding="0" cellspacing="0">
							<tr>
								<td valign="top" class="breadcrumbtd">









	
	
	
		
	
	
		
		
			
			
			
			
			
			
			
		
		
	


<table cellpadding="0" cellspacing="0" class="breadcrumb">
	<tr>
		<td style="white-space:nowrap;" class="breadcrumb">
			
				
				<div style="white-space:nowrap; float:left" class="breadcrumb"><a href="default.cfm?id=1" class="breadcrumb">Home</a></div>
				<div style="white-space:nowrap; float:left" class="breadcrumb_between"><img src="images/breadcrumb_divider.gif"></div>
				
			
			
				
						
				
				<div style="white-space:nowrap; float:left" class="breadcrumb"><a href="body.cfm?id=54&amp;oTopId=54" class="breadcrumb">Contact Us</a></div>
							
			
		</td>
	</tr>
</table>
</td>
							</tr>
							<tr class="content">														
								<td valign="top" style="padding:12px;">
									
										
											
										
										
											
												
												
													
														<h1 class="pagetitle" id="pagetitle"><strong>Contact Form - UCLA Center for Esophageal Disorders</strong></h1>
													
												
											
										
										
										<div id="bodycontent">
										











	
		
		
		
		
	<script type="text/javascript" src="http://www.uclahealth.org/sitemaker/sm_FormValidation.js"></script>
			<script language="JavaScript" type="text/javascript">
			<!--
			var smm_eforms_toggle_other_to_init = new Array();
			function smm_eforms_toggle_other_init() {
				var i = 0;
				var o = null;
				var strFEType = null;
				var bCallToggler = null;
				for (i = 0; i < smm_eforms_toggle_other_to_init.length; i++) {
					o = document.getElementById(smm_eforms_toggle_other_to_init[i]);
					if (o != null) {
						if (o.type) {
							strFEType = o.type;
							switch (strFEType) {
								case "radio":
								{
									bCallToggler = o.checked;
									break;
								}
								case "checkbox":
								{
									bCallToggler = (o.value.toLowerCase() == 'other');
									break;
								}
								case "select-one": {
									bCallToggler = true;
									break;
								}
								default: {
									bCallToggler = false;
									break;
								}
							}
						} else {
							strFEType = "";
						}
						if (bCallToggler) {
							smm_eforms_toggle_other(o);
						}
					}
				}
				return true;
			}
			var smm_eforms_displayEformsForm_onLoadBackup = null;
			function smm_eforms_displayEformsForm_onLoad() {
				if (smm_eforms_displayEformsForm_onLoadBackup != null) {
					smm_eforms_displayEformsForm_onLoadBackup();
				}
				smm_eforms_toggle_other_init();
				return true;
			}
			if (window.onload && window.onload != null) {
				smm_eforms_displayEformsForm_onLoadBackup = window.onload;
			}
			window.onload = smm_eforms_displayEformsForm_onLoad;
			function smm_eforms_toggle_other(oFormElement) {
				var strSourceName = oFormElement.name;
				var strSourceId = strSourceName + "_other";
				var strTargetId = strSourceId + "_txt";
				var oForm = oFormElement.form;
				var oSource = oForm[strSourceId];
				var oTarget = oForm[strTargetId];
				var oTartgetReq = oForm[strTargetId + "_required"];
				var strFEType = oFormElement.type;
				if (strFEType=='checkbox' || strFEType=='radio'){
					if (oSource.checked){
						oTarget.disabled=false;
						oTartgetReq.name=strTargetId + '_required';
					} else {
						oTarget.value='';
						oTarget.disabled=true;
						oTartgetReq.name=strTargetId + '_notreq';
					}
				} else {
					oSource = oForm[strSourceName];
					if (oSource.options[oSource.options.length-1].selected){
						oTarget.disabled=false;
						oTartgetReq.name=strTargetId + '_required';
					} else {
						oTarget.value='';
						oTarget.disabled=true;
						oTartgetReq.name=strTargetId + '_notreq';
					}
				}
			}
			//-->
			</script>
		<form name="eform" method="post" action="http://esophagealcenter.ucla.edu/body.cfm?xyzpdqabc=0&amp;id=54&amp;action=submiteform" onSubmit="return (sm_ValidateForm(this) && sm_removeALLrequiredhiddenfields(this));" class="metadetail">
		<table class="metadetail">
			<tr class="metadetail">
				<td class="metadetail" colspan="2"><img src="images/images/contact_us.jpg" alt="Contact Us" width="200" height="268" hspace="7" vspace="0" border="0" align="right" class="sm6generalwizard" /><br>Phone: (310)825-6167<br>Fax: (310)794-7335<br><br>UCLA Center for Esophageal Disorders<br>10833 Le Conte Avenue, CHS 64-123<br>Los Angeles, CA 90095<br><br>To contact us via email please fill out this form:<br><br></td>
			</tr>
			<tr class="metadetail">
				<td class="metadetail" colspan="2"><span class="required">
				* Indicates required information</span></td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Name&nbsp;<span class="required">*</span>&nbsp;</th>
				<td class="metadetail">
					<input type="Text" name="eformField_1" class="metadetail" size="35" value="">
					<input type="Hidden" name="eformField_1_required" class="metadetail" value="Name is required.">
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Email Address&nbsp;<span class="required">*</span>&nbsp;</th>
				<td class="metadetail">
					<input type="Text" name="eformField_2" class="metadetail" size="35" value="">
					  
					<input type="Hidden" name="eformField_2_email" class="metadetail" value="Email Address must be a valid email address.">
					<input type="Hidden" name="eformField_2_required" class="metadetail" value="Email Address is required.">
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Phone Number&nbsp;<span class="required">*</span>&nbsp;</th>
				<td class="metadetail">
					<input type="Text" name="eformField_3" class="metadetail" size="35" value="">
					<input type="Hidden" name="eformField_3_required" class="metadetail" value="Phone Number is required.">
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Street Address 1&nbsp;<span class="required">*</span>&nbsp;</th>
				<td class="metadetail">
					<input type="Text" name="eformField_4" class="metadetail" size="35" value="">
					<input type="Hidden" name="eformField_4_required" class="metadetail" value="Street Address 1 is required.">
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Street Address 2&nbsp;</th>
				<td class="metadetail">
					<input type="Text" name="eformField_5" class="metadetail" size="35" value="">
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">State&nbsp;<span class="required">*</span>&nbsp;</th>
				<td class="metadetail">
					<select name="eformField_6" id="eformField_6" class="metadetail">
						<option value="AK" selected>AK</option>
						<option value="AL">AL</option>
						<option value="AR">AR</option>
						<option value="AZ">AZ</option>
						<option value="CA">CA</option>
						<option value="CO">CO</option>
						<option value="CT">CT</option>
						<option value="DC">DC</option>
						<option value="DE">DE</option>
						<option value="FL">FL</option>
						<option value="GA">GA</option>
						<option value="HI">HI</option>
						<option value="IA">IA</option>
						<option value="ID">ID</option>
						<option value="IL">IL</option>
						<option value="IN">IN</option>
						<option value="KS">KS</option>
						<option value="KY">KY</option>
						<option value="LA">LA</option>
						<option value="MA">MA</option>
						<option value="MD">MD</option>
						<option value="ME">ME</option>
						<option value="MI">MI</option>
						<option value="MN">MN</option>
						<option value="MO">MO</option>
						<option value="MS">MS</option>
						<option value="MT">MT</option>
						<option value="NC">NC</option>
						<option value="ND">ND</option>
						<option value="NE">NE</option>
						<option value="NH">NH</option>
						<option value="NJ">NJ</option>
						<option value="NM">NM</option>
						<option value="NV">NV</option>
						<option value="NY">NY</option>
						<option value="OH">OH</option>
						<option value="OK">OK</option>
						<option value="OR">OR</option>
						<option value="PA">PA</option>
						<option value="PR">PR</option>
						<option value="RI">RI</option>
						<option value="SC">SC</option>
						<option value="SD">SD</option>
						<option value="TN">TN</option>
						<option value="TX">TX</option>
						<option value="UT">UT</option>
						<option value="VA">VA</option>
						<option value="VT">VT</option>
						<option value="WA">WA</option>
						<option value="WI">WI</option>
						<option value="WV">WV</option>
						<option value="WY">WY</option>
					</select>
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">City&nbsp;<span class="required">*</span>&nbsp;</th>
				<td class="metadetail">
					<input type="Text" name="eformField_7" class="metadetail" size="35" value="">
					<input type="Hidden" name="eformField_7_required" class="metadetail" value="City is required.">
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Zip&nbsp;<span class="required">*</span>&nbsp;</th>
				<td class="metadetail">
					<input type="Text" name="eformField_8" class="metadetail" size="35" value="">
					<input type="Hidden" name="eformField_8_required" class="metadetail" value="Zip is required.">
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Country&nbsp;<span class="required">*</span>&nbsp;</th>
				<td class="metadetail">
					<input type="Text" name="eformField_9" class="metadetail" size="35" value="">
					<input type="Hidden" name="eformField_9_required" class="metadetail" value="Country is required.">
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Appointment&nbsp;</th>
				<td class="metadetail">
					<span style="white-space:nowrap;"><input type="checkbox" name="eformField_10" id="eformField_10_1" style="{border:0;}" value="I would like an appointment">
					<label for="eformField_10_1" class="metadetail">I would like an appointment</label></span><br>
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">I would like information:&nbsp;</th>
				<td class="metadetail">
					<span style="white-space:nowrap;"><input type="checkbox" name="eformField_11" id="eformField_11_1" style="{border:0;}" value="GERD (reflux disease)">
					<label for="eformField_11_1" class="metadetail">GERD (reflux disease)</label></span><br>
						<script language="JavaScript" type="text/javascript"><!--
						smm_eforms_toggle_other_to_init[smm_eforms_toggle_other_to_init.length] = "eformField_11_1";
						//--></script>
					<span style="white-space:nowrap;"><input type="checkbox" name="eformField_11" id="eformField_11_2" style="{border:0;}" value="Achalasia">
					<label for="eformField_11_2" class="metadetail">Achalasia</label></span><br>
						<script language="JavaScript" type="text/javascript"><!--
						smm_eforms_toggle_other_to_init[smm_eforms_toggle_other_to_init.length] = "eformField_11_2";
						//--></script>
					<span style="white-space:nowrap;"><input type="checkbox" name="eformField_11" id="eformField_11_3" style="{border:0;}" value="Esophageal cancer">
					<label for="eformField_11_3" class="metadetail">Esophageal cancer</label></span><br>
						<script language="JavaScript" type="text/javascript"><!--
						smm_eforms_toggle_other_to_init[smm_eforms_toggle_other_to_init.length] = "eformField_11_3";
						//--></script>
					<span style="white-space:nowrap;"><input type="checkbox" name="eformField_11" id="eformField_11_4" style="{border:0;}" value="Swallowing disorders">
					<label for="eformField_11_4" class="metadetail">Swallowing disorders</label></span><br>
						<script language="JavaScript" type="text/javascript"><!--
						smm_eforms_toggle_other_to_init[smm_eforms_toggle_other_to_init.length] = "eformField_11_4";
						//--></script>
					<span style="white-space:nowrap;"><input type="checkbox" name="eformField_11" id="eformField_11_other" style="{border:0;}" value='Other' onClick="return smm_eforms_toggle_other(this);">
					<label for="eformField_11_other" class="metadetail">Other</label></span>
					<div class="metanew">
						<p class="metanew">
							If Other, please specify:<br>
							<textarea cols="30" rows="3" name="eformField_11_other_txt" id="eformField_11_other_" disabled class="metadetail"></textarea>
						</p>
					</div>
					<script language="JavaScript" type="text/javascript"><!--
					smm_eforms_toggle_other_to_init[smm_eforms_toggle_other_to_init.length] = "eformField_11_other";
					//--></script>
					<input type="hidden" name="eformField_11_other_txt_required" value='Please provide further details to your answer: Other.' disabled>
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Contact me regarding:&nbsp;</th>
				<td class="metadetail">
					<textarea name="eformField_12" class="metadetail" cols="40" rows="5"></textarea>
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">I have been diagnosed with, <br>or I think I have:&nbsp;</th>
				<td class="metadetail">
					<span style="white-space:nowrap;"><input type="checkbox" name="eformField_13" id="eformField_13_1" style="{border:0;}" value="Achalasia">
					<label for="eformField_13_1" class="metadetail">Achalasia</label></span><br>
						<script language="JavaScript" type="text/javascript"><!--
						smm_eforms_toggle_other_to_init[smm_eforms_toggle_other_to_init.length] = "eformField_13_1";
						//--></script>
					<span style="white-space:nowrap;"><input type="checkbox" name="eformField_13" id="eformField_13_2" style="{border:0;}" value="Barrett's Esophagus">
					<label for="eformField_13_2" class="metadetail">Barrett's Esophagus</label></span><br>
						<script language="JavaScript" type="text/javascript"><!--
						smm_eforms_toggle_other_to_init[smm_eforms_toggle_other_to_init.length] = "eformField_13_2";
						//--></script>
					<span style="white-space:nowrap;"><input type="checkbox" name="eformField_13" id="eformField_13_3" style="{border:0;}" value="Diffuse esophageal spasm">
					<label for="eformField_13_3" class="metadetail">Diffuse esophageal spasm</label></span><br>
						<script language="JavaScript" type="text/javascript"><!--
						smm_eforms_toggle_other_to_init[smm_eforms_toggle_other_to_init.length] = "eformField_13_3";
						//--></script>
					<span style="white-space:nowrap;"><input type="checkbox" name="eformField_13" id="eformField_13_4" style="{border:0;}" value="Esophageal cancer">
					<label for="eformField_13_4" class="metadetail">Esophageal cancer</label></span><br>
						<script language="JavaScript" type="text/javascript"><!--
						smm_eforms_toggle_other_to_init[smm_eforms_toggle_other_to_init.length] = "eformField_13_4";
						//--></script>
					<span style="white-space:nowrap;"><input type="checkbox" name="eformField_13" id="eformField_13_5" style="{border:0;}" value="GERD">
					<label for="eformField_13_5" class="metadetail">GERD</label></span><br>
						<script language="JavaScript" type="text/javascript"><!--
						smm_eforms_toggle_other_to_init[smm_eforms_toggle_other_to_init.length] = "eformField_13_5";
						//--></script>
					<span style="white-space:nowrap;"><input type="checkbox" name="eformField_13" id="eformField_13_other" style="{border:0;}" value='Other' onClick="return smm_eforms_toggle_other(this);">
					<label for="eformField_13_other" class="metadetail">Other</label></span>
					<div class="metanew">
						<p class="metanew">
							If Other, please specify:<br>
							<textarea cols="30" rows="3" name="eformField_13_other_txt" id="eformField_13_other_" disabled class="metadetail"></textarea>
						</p>
					</div>
					<script language="JavaScript" type="text/javascript"><!--
					smm_eforms_toggle_other_to_init[smm_eforms_toggle_other_to_init.length] = "eformField_13_other";
					//--></script>
					<input type="hidden" name="eformField_13_other_txt_required" value='Please provide further details to your answer: Other.' disabled>
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Symptoms <br>(check all that apply):&nbsp;</th>
				<td class="metadetail">
					<span style="white-space:nowrap;"><input type="checkbox" name="eformField_14" id="eformField_14_1" style="{border:0;}" value="Heartburn">
					<label for="eformField_14_1" class="metadetail">Heartburn</label></span><br>
						<script language="JavaScript" type="text/javascript"><!--
						smm_eforms_toggle_other_to_init[smm_eforms_toggle_other_to_init.length] = "eformField_14_1";
						//--></script>
					<span style="white-space:nowrap;"><input type="checkbox" name="eformField_14" id="eformField_14_2" style="{border:0;}" value="Regurgitation">
					<label for="eformField_14_2" class="metadetail">Regurgitation</label></span><br>
						<script language="JavaScript" type="text/javascript"><!--
						smm_eforms_toggle_other_to_init[smm_eforms_toggle_other_to_init.length] = "eformField_14_2";
						//--></script>
					<span style="white-space:nowrap;"><input type="checkbox" name="eformField_14" id="eformField_14_3" style="{border:0;}" value="Difficulty swallowing">
					<label for="eformField_14_3" class="metadetail">Difficulty swallowing</label></span><br>
						<script language="JavaScript" type="text/javascript"><!--
						smm_eforms_toggle_other_to_init[smm_eforms_toggle_other_to_init.length] = "eformField_14_3";
						//--></script>
					<span style="white-space:nowrap;"><input type="checkbox" name="eformField_14" id="eformField_14_4" style="{border:0;}" value="Chest Pain">
					<label for="eformField_14_4" class="metadetail">Chest Pain</label></span><br>
						<script language="JavaScript" type="text/javascript"><!--
						smm_eforms_toggle_other_to_init[smm_eforms_toggle_other_to_init.length] = "eformField_14_4";
						//--></script>
					<span style="white-space:nowrap;"><input type="checkbox" name="eformField_14" id="eformField_14_other" style="{border:0;}" value='Other' onClick="return smm_eforms_toggle_other(this);">
					<label for="eformField_14_other" class="metadetail">Other</label></span>
					<div class="metanew">
						<p class="metanew">
							If Other, please specify:<br>
							<textarea cols="30" rows="3" name="eformField_14_other_txt" id="eformField_14_other_" disabled class="metadetail"></textarea>
						</p>
					</div>
					<script language="JavaScript" type="text/javascript"><!--
					smm_eforms_toggle_other_to_init[smm_eforms_toggle_other_to_init.length] = "eformField_14_other";
					//--></script>
					<input type="hidden" name="eformField_14_other_txt_required" value='Please provide further details to your answer: Other.' disabled>
				</td>
			</tr>
			<tr>
				<th class="metadetail">&nbsp;</th>
				<td class="metadetail">
				
					
				
	<script>
	var RecaptchaOptions = {
	   theme : 'custom',
	   tabindex : 2,
	   custom_theme_widget: 'recaptcha_widget'
	};
	</script>
	<strong>Security Check</strong><br>
	<div>
		<div id="recaptcha_image" style="border:1px solid efefef; padding:7px; float:left;"></div>
		<div>
			<div style="padding-bottom:4px;"><img src="https://www.uclahealth.org/images/recaptcha-credit.gif"></div>
			<div style="padding-bottom:1px;"><a href="javascript:Recaptcha.reload()"><img src="https://www.uclahealth.org/images/recaptcha-new.gif" border="0" hspace="3" align="absmiddle"></a></div>
			<div style="padding-bottom:1px;" class="recaptcha_only_if_image"><a href="javascript:Recaptcha.switch_type('audio')"><img src="https://www.uclahealth.org/images/recaptcha-impaired.gif" border="0" hspace="3" align="absmiddle"></a></div>
			<div style="padding-bottom:1px;" class="recaptcha_only_if_audio"><a href="javascript:Recaptcha.switch_type('image')"><img src="https://www.uclahealth.org/images/recaptcha-impaired2.gif" border="0" hspace="3" align="absmiddle"></a></div>
			<div style="padding-bottom:1px;"><a href="javascript:Recaptcha.showhelp()"><img src="https://www.uclahealth.org/images/recaptcha-help.gif" border="0" hspace="3" align="absmiddle"></a></div>
		</div>
	</div>
	<div class="recaptcha_only_if_incorrect_sol" style="color:red">Incorrect please try again</div>
	<div style="clear:both; height:15px;"></div>
	<span class="recaptcha_only_if_image"><strong>Type both words separated by a space below:</strong></span>
	<span class="recaptcha_only_if_audio"><strong>Type the numbers you hear:</strong></span>
	<br>
	<input type="text" id="recaptcha_response_field" name="recaptcha_response_field" size="30" />
	<script type="text/javascript" src="https://api-secure.recaptcha.net/challenge?k=6LcAYAQAAAAAAFuC4fcVvS38Hk9m2Uin6CWofs4Y&lang=en"></script>
	<noscript>
	  <iframe src="https://api-secure.recaptcha.net/noscript?k=6LcAYAQAAAAAAFv8vTrn3M_dbn6_eN9P9Zyz4oF9&lang=en" height="300" width="500" frameborder="0"></iframe><br />
	  <textarea name="recaptcha_challenge_field" rows="3" cols="40"></textarea>
	  <input type='hidden' name='recaptcha_response_field' value='manual_challenge' />
	</noscript>
				</td>
			</tr>
			<tr class="metadetail">
				<th class="metadetail">&nbsp;</th>
				<td class="metadetail">
					<input type="submit" name="submit" value="Submit" class="metadetail">
				</td>
			</tr>
		</table>
		</form>
	
	
 
									
										</div>
									
								</td>
							</tr>
						</table>
						<p>&nbsp;</p>
						
					</td>									
				</tr>
			</table>
		</td>
	</tr>
	<tr>
		<td valign="top" bgcolor="#e5ebeb">
			<table width="100%" border="0" cellpadding="0" cellspacing="0">
				<tr>
					<td width="960" height="34" align="center" valign="middle" style="border-top:1px dashed #999999; padding-bottom:2px;" class="navbarnum4">
						
	<!-- Begin NavBar Output  -  Version:  v0.79a 09/30/2006  -->
	
		<!-- Begin NavBar Bar #2 Content Output... -->
		<table  border="0" cellspacing="0" cellpadding="0" onclick="NavBar_deleteCookie();">
	<tr class="navbarnum4">
		<td class="navbarnum4" valign="bottom" align="left" title=""><a href="http://www.ucla.edu"  target="_blank" onMouseOver="RestoreAll();nbMouseover('footer_ucla_2_1','images/footer_ucla.gif','');" onMouseOut ="nbMouseoverRestore();" onClick="NavBar_setPLinkIDCookie('16','');" class="navbarnum4"><img src="images/footer_ucla.gif" border="0" alt="UCLA Home" id="footer_ucla_2_1" name="footer_ucla_2_1"></a></td>
		<td class="navbarnum4" valign="bottom" align="left" title="">&nbsp;&nbsp;&nbsp;&nbsp;</td>
		<td class="navbarnum4" valign="bottom" align="left" title=""><a href="http://www.uclahealth.org"  target="_blank" onClick="NavBar_setPLinkIDCookie('15','');" class="navbarnum4">UCLA Health System</a></td>
		<td class="navbarnum4" valign="bottom" align="left" title="">&nbsp;&nbsp;&nbsp;&nbsp;</td>
		<td class="navbarnum4" valign="bottom" align="left" title=""><a href="http://www.ucla.edu/terms.html"  target="_blank" onClick="NavBar_setPLinkIDCookie('14','');" class="navbarnum4">Terms of Use / ©2009 UC Regents</a></td>
		<td class="navbarnum4" valign="bottom" align="left" title="">&nbsp;&nbsp;&nbsp;&nbsp;</td>
		<td class="navbarnum4" valign="bottom" align="left" title=""><a href="http://www.uclahealth.org/body.cfm?id=57"  target="_blank" onClick="NavBar_setPLinkIDCookie('13','');" class="navbarnum4">Privacy Practices</a></td>
		<td class="navbarnum4" valign="bottom" align="left" title="">&nbsp;&nbsp;&nbsp;&nbsp;</td>
		<td class="navbarnum4" valign="bottom" align="left" title=""><a href="http://www.accessweb.ucla.edu"  target="_blank" onMouseOver="RestoreAll();nbMouseover('footer_wheelchair_2_5','images/footer_wheelchair.gif','');" onMouseOut ="nbMouseoverRestore();" onClick="NavBar_setPLinkIDCookie('12','');" class="navbarnum4"><img src="images/footer_wheelchair.gif" border="0" alt="Disability Resources" id="footer_wheelchair_2_5" name="footer_wheelchair_2_5"></a></td>
		<td class="navbarnum4" valign="bottom" align="left" title="">&nbsp;&nbsp;&nbsp;&nbsp;</td>
		<td class="navbarnum4" valign="bottom" align="left" title=""><a href="body.cfm?id=11"  onClick="NavBar_setPLinkIDCookie('11','');" class="navbarnum4">Sitemap</a></td>
	</tr>
</table>
	
		<!-- End NavBar Output -->
	 

					</td>
				</tr>
			</table>
		</td>
	</tr>
</table>
</body>
</html>