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				<td class="metadetail">
					<span style="white-space:nowrap;"><input type="radio" name="eformField_11" id="eformField_11_1" style="{border:0;}" value="yes">
					<label for="eformField_11_1" class="metadetail">yes</label></span>
					<span style="white-space:nowrap;"><input type="radio" name="eformField_11" id="eformField_11_2" style="{border:0;}" value="no" checked>
					<label for="eformField_11_2" class="metadetail">no</label></span>
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">How did you hear about us?&nbsp;<span class="required">*</span>&nbsp;</th>
				<td class="metadetail">
					<select name="eformField_12" id="eformField_12" class="metadetail" onChange="return smm_eforms_toggle_other(this);">
						<option value="Select one:" selected>Select one:</option>
						<option value="TV - WMAR Channel 2">TV - WMAR Channel 2</option>
						<option value="TV - WBAL Channel 11">TV - WBAL Channel 11</option>
						<option value="TV - WJZ Channel 13">TV - WJZ Channel 13</option>
						<option value="Web - abc2news.com">Web - abc2news.com</option>
						<option value="Web - wbaltv.com">Web - wbaltv.com</option>
						<option value="Web - wjz.com">Web - wjz.com</option>
						<option value="Web - hospital/MedStar site">Web - hospital/MedStar site</option>
						<option value="Radio - WBAL">Radio - WBAL</option>
						<option value="Radio - WYPR">Radio - WYPR</option>
						<option value="Destinations Newsletter">Destinations Newsletter</option>
						<option value="Hospital E-Newsletter">Hospital E-Newsletter</option>
						<option value="The Baltimore Sun">The Baltimore Sun</option>
						<option value="baltimoresun.com">baltimoresun.com</option>
						<option value="Community Newspaper">Community Newspaper</option>
						<option value="Doctor">Doctor</option>
						<option value="Word of Mouth">Word of Mouth</option>
						<option value="Electronic Messaging Billboard/Sign">Electronic Messaging Billboard/Sign</option><option value='Other'>Other</option>
					</select>
					<div class="metanew">
						<p class="metanew">
							If Other, please specify:<br>
							<textarea cols="30" rows="3" name="eformField_12_other_txt" 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_12";
					//--></script>
					<input type="hidden" name="eformField_12_other_txt_required" value='Please provide further details to your answer: Other.' disabled>
				</td>
			</tr>
			<tr class="metadetail">
				<th class="metadetail">&nbsp;</th>
				<td class="metadetail">
					<input type="submit" name="submit" value="Submit" class="metadetail">
				</td>
			</tr>
			<tr class="metadetail">
				<td class="metadetail" colspan="2"><br><span class=footnote>Union Memorial Hospital and its parent company, MedStar Health, respect your privacy. The information you submit is used for internal purposes only to help guide us in developing health information relevant to your needs.</span></td>
			</tr>
		</table>
		</form>
	
	
																	</td>
																</tr>
															</table>
														</td>
														
														<td align="left" valign="top"></td>
														
													</tr>
												</table>
											</td>
										</tr>
									</table>
								</td>
							</tr>
						</table>
					</td>
				</tr>
			</table>
			<table width="100%" border="0" cellpadding="0" cellspacing="0">
	<tr>
		
		<td align="center" width="10" height="5"></td>
	</tr>
	<tr>
		
		<td align="left" valign="top" width="100%">
			<table border="0" cellpadding="0" cellspacing="0" valign="top">
				
				
				<tr>
					<td>
						<span class="footerlinks">
						<a href="http://www.medstarhealth.org/" class="footerlinks" target="_blank">
							MedStar Health Facilities
						</a>
						</span>
					</td>
					<td>
						<span class="footertext">
							&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
							Union Memorial Hospital &nbsp; 201 East University Parkway, Baltimore, MD 21218
							&nbsp;410.554.2000
							&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
							&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
							&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
							E.O.E.&nbsp;&nbsp;
						</span>
					</td>
					<td>
						<span class="footerlinks">
						<a href="http://www.medstarhealth.org/body.cfm?id=385" class="footerlinks" target="_blank">
							Notice of Privacy Practices&nbsp;&nbsp;
						</a>
						</span>
					</td>
					<td>
						<span class="footerlinks">
						<a href="body.cfm?id=329" class="footerlinks">
							Disclaimer
						</a>
						</span>
					</td>
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