Appointment form

I have the fields I need here: [login to view URL] Need Captcha or equivilent security Also need to add "How did you hear about us (something that will allow patient to choose either: [ ]Browsed in, [ ]Search engine, [ ]Billboard, [ ]Mall ad, [ ]Friend [ ]Physician (Dr._____________), Other (please list:___________ etc) field on this form: Click the get started button at [login to view URL]