" name="my_form">
Date:
' title='' onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)' />
'>
Name:
Date of Birth:
' title='' onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc);' />
'>
Phone:
Address:
Use this space to express notes
<?php echo stripslashes($record['notes']);?>
Signature?
>Yes /
>No Date of signature:
' title='' onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)' />
'>