재시아성형외과

<form method="post" name="frm2" id="frm2" action="http://log.arcrm.kr/outside/add" onsubmit="return submitCheck()" enctype="multipart/form-data">
<input type='hidden' name='campaign_index' value='c1404071415'>
<input type="hidden" name="memo" class="memo" value="">
<div style="position:relative;">
<div style="position:absolute;left:-5px;top:-5px;"><img src='http://crm.drcom.co.kr/data/media/image/mem1/201307/505c06a4cc05a.gif' border='0'style="cursor:pointer;" onClick="document.getElementById('phone_area').style.display='none';"></div>
<img src='http://crm.drcom.co.kr/data/media/image/mem1/201307/505ad2ee8198b.png' usemap="#dscrmphone1" border='0'>
<map name="dscrmphone1">
<area shape="rect" coords="21, 351, 120, 379" href="#" onClick="layer_show_hide(1);return false;">
<area shape="rect" coords="121, 351, 218, 380" href="#" onClick="layer_show_hide(2);return false;">
</map>
<div style="position:absolute;left:25px;top:120px;width:190px;">
<table style="font-size:9pt;font-family:맑은 고딕;font-weight:bold;color:#515151;" border="0" cellpadding="1" cellspacing="0">
<tr><td width=55>이름</td><td style="text-align:justify;">
<input type="text" name="name" class="name" style="border:1px solid #cccccc;width:120px;">
</td></tr>
<tr><td>휴대폰</td><td>
<input type="text" name="hp1" class="hp1" style="border:1px solid #cccccc;width:36px;">
<input type="text" name="hp2" class="hp2" style="border:1px solid #cccccc;width:37px;">
<input type="text" name="hp3" class="hp3" style="border:1px solid #cccccc;width:37px;">
</td></tr>
<tr><td>성별</td><td>
<select name="gender" class="gender" style="font-size:9pt;font-family:맑은 고딕;color:#515151;width:120px;">
<option value="여성" selected>여성</option>
<option value="남성">남성</option>
</select>
</td></tr>
<tr><td>연령</td><td>
<select name="age" class="age" style="font-size:9pt;font-family:맑은 고딕;color:#515151;width:120px;">
<option value="10대" selected>10대</option>
<option value="20대">20대</option>
<option value="30대">30대</option>
<option value="40대">40대</option>
<option value="50대">50대</option>
<option value="60대">60대</option>
</select>
</td></tr>
<tr><td>거주지</td><td>
<select name="addr" class="addr" style="font-size:9pt;font-family:맑은 고딕;color:#515151;width:120px;">
<option value="서울">서울</option>
<option value="인천">인천</option>
<option value="경기">경기</option>
<option value="부산">부산</option>
<option value="대전">대전</option>
<option value="대구">대구</option>
<option value="울산">울산</option>
<option value="광주">광주</option>
<option value="강원">강원</option>
<option value="충북">충북</option>
<option value="충남">충남</option>
<option value="전북">전북</option>
<option value="전남">전남</option>
<option value="경북">경북</option>
<option value="경남">경남</option>
</select>
</td></tr>
<tr><td>관심부위</td><td>
<select name="hope_part" style="font-size:9pt;font-family:맑은 고딕;color:#515151;width:120px;">
<option value="짧은코">짧은코</option>
<option value="매부리코">매부리코</option>
<option value="넓은코">넓은코</option>
<option value="콧볼축소">콧볼축소</option>
<option value="매몰법">매몰법</option>
<option value="절개법">절개법</option>
<option value="눈매교정">눈매교정</option>
<option value="앞,뒷트임">앞,뒷트임</option>
<option value="하안검">하안검</option>
<option value="눈밑지방제거">눈밑지방제거</option>
<option value="윗눈썹밑절제술">윗눈썹밑절제술</option>
<option value="광대축소">광대축소</option>
<option value="무턱보형물">무턱보형물</option>
<option value="이마보형물">이마보형물</option>
</select>
</td></tr>
</table>
<div style="font-size:8pt;font-family:맑은 고딕;text-align:center;"><input type="checkbox" name='is_agree' id='is_agree' checked>개인정보 수집 및 사용에 동의<br>
<a href="http://crm.drcom.co.kr/crm/agreement/c1374546293183" target=_blank>[자세히 보기]</a></div>
<div style="font-size:8pt;font-family:맑은 고딕;text-align:center;margin-top:10px;">
<input type='image' src='http://crm.drcom.co.kr/data/media/image/mem1/201307/505adf396ff38.png' border='0'>
</div>
</div>
</div>
</form>