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	Family Practice Channahon
 </span></a><br>
			
               <input type="radio" name="sectorSiteID" id="sectorSiteID"  value="D0A"  /><a href="http://www.provena.org/stjoes/body.cfm?id=538&oTopID=538" target="_blank"><span  id="cf_tooltip_1283996090253">
	
	Family Practice Coal City
 </span></a><br>
			
               <input type="radio" name="sectorSiteID" id="sectorSiteID"  value="D70"  /><a href="http://www.provena.org/stjoes/body.cfm?id=1106&oTopID=538" target="_blank"><span  id="cf_tooltip_1283996090254">
	
	Internal Medicine & Pediatrics Lockport
 </span></a><br>
			
               <input type="radio" name="sectorSiteID" id="sectorSiteID"  value="D72"  /><a href="http://www.provena.org/stjoes/body.cfm?id=539&oTopID=538" target="_blank"><span  id="cf_tooltip_1283996090255">
	
	Provena Medical Group New Lenox Cedar
 </span></a><br>
			
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	Family Practice New Lenox
 </span></a><br>
			
               <input type="radio" name="sectorSiteID" id="sectorSiteID"  value="D64"  /><a href="http://www.provena.org/stjoes/body.cfm?id=806&oTopID=538" target="_blank"><span  id="cf_tooltip_1283996090257">
	
	Family Practice Manhattan
 </span></a><br>
			
               <input type="radio" name="sectorSiteID" id="sectorSiteID"  value="D67"  /><a href="http://www.provena.org/stjoes/body.cfm?id=1064&oTopID=812" target="_blank"><span  id="cf_tooltip_1283996090258">
	
	Senior Health Center Plainfield
 </span></a><br>
			
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           <input type="checkbox" name="preferredTourTime" id="preferredTourTime"  value="Afternoon" /> Afternoon<br>
           <input type="checkbox" name="preferredTourTime" id="preferredTourTime"  value="Evening" /> Evening<br>
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           <input type="radio" name="patientType" id="patientType"  value="Returning Patient" /> Returning Patient<br>

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