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<CENTER> <h2>ABDULLAHPAŞA 1 NOLU AİLE SAĞLIĞI MERKEZİ <BR /> GEBE BİLDİRİM FORMU</h2><BR /></CENTER> 
  <form name="contact" method="post" action="">
  <fieldset>
  
  <label for="ad" id="ad_label">ADI *</label>
  <input type="text" name="ad" id="ad" size="30" value="" class="text-input" />
  <label class="error" for="ad" id="ad_error">Lütfen Gebinin Adını Giriniz.</label><br />

  <label for="soyad" id="soyad_label">SOYADI *</label>
  <input type="text" name="soyad" id="soyad" size="30" value="" class="text-input" />
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  <label for="ailehek" id="ailehek_label">AİLE HEKİMİ *</label>
  <select class="text-input" name="ailehek" id="ailehek">
  <option value="0" selected="selected">LİSTEDEN SEÇİNİZ</option>
  
      <option value="Dr. Levent TÜRKMEN">Dr. Levent TÜRKMEN</option>
	   <option value="Dr. Faruk AKSOY">Dr. Faruk AKSOY</option>
	    <option value="Dr. Nesrin DEMİR">Dr. Nesrin DEMİR</option>
		 <option value="Dr. Atilla ORHAN">Dr. Atilla ORHAN</option>
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  <p><strong>* Size Ulaşabilmemiz İçin, Lütfen Bilgileri Doğru ve Eksiksiz Doldurunuz.<br />
    * Telefon Numarası ve Adres Size Ulaşabilmemiz İçin Gereklidir.
  </strong></p>
  <p><strong>* Buradaki Bilgilerin Bağlı Bulunduğunuz Aile Hekimine Ulaşabilmesi İçin Lütfen &quot;AİLE HEKİMİ&quot; Listesinden Kayıtlı Olduğunuz Aile Hekimini Seçiniz...</strong></p></div>
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