Cosmetic Surgery Checklist
", $address);
$address = str_replace(chr(34),""", $address);
$address = str_replace("'","'", $address);
$txtPhoneNumber = $_REQUEST['txtPhoneNumber'];
$txtEmail = $_REQUEST['txtEmail'];
$cmbAgeRange = $_REQUEST['cmbAgeRange'];
$hospital_cover = $_REQUEST['hospital_cover'];
$newsletter = $_REQUEST['newsletter'];
$comments = trim($_REQUEST['comments']);
$comments = str_replace(chr(13),"
", $comments);
$comments = str_replace(chr(34),""", $comments);
$comments = str_replace("'","'", $comments);
$how_found = $_REQUEST['how_found'];
$ContactPerson = "Sir / Madam";
$domineName=$_SERVER['HTTP_HOST'];
$mailbody = '';
$mailbody .='Dear '.$ContactPerson.',
';
$mailbody .='';
$mailbody .='| Indigo - Enrollment form | ';
$mailbody .='| First Name | ';
$mailbody .=' | '.$txtName.' | ';
$mailbody .=' ';
$mailbody .='| Last Name | ';
$mailbody .=''.$txtLastName.' | ';
$mailbody .='| Address | ';
$mailbody .=''.$address.' | ';
$mailbody .='| Phone Number | ';
$mailbody .=''.$txtPhoneNumber.' | ';
$mailbody .='| Email Address | ';
$mailbody .=''.$txtEmail.' | ';
$mailbody .='| Procedure of Interest | ';
$mailbody .=''.$cmbAgeRange.' | ';
$mailbody .='| Private Health Insurance (Hospital Cover) | ';
$mailbody .=''.$hospital_cover.' | ';
$mailbody .='| Would you like to receive news and special offers from time to time via an e-newsletter? | ';
$mailbody .=''.$newsletter.' | ';
$mailbody .='| Comments or Question | ';
$mailbody .=''.$comments.' | ';
$mailbody .='| How did you find us? | ';
$mailbody .=''.$how_found.' | ';
$mailbody .=' ';
$mailbody .= '
Thank You
';
$mailbody .='Regards,
';
$mailbody .= $txtName;
$mailbody .= '';
//echo $mailbody;exit;
// Read POST request params into global vars
//$to = "indigoconsulting@exemail.com.au";
$to = "ajayk5813@gmail.com";
$from = $_REQUEST['EmailAddress'];
$semi_rand = md5(time());
$mime_boundary = "==Multipart_Boundary_x{$semi_rand}x";
//$headers = "MIME-Version: 1.0\r\n";
//$headers .= "Content-type: text/html; charset=UTF-8\r\n";
$headers = "From: $from";
$headers .= "\nMIME-Version: 1.0\n" .
"Content-Type: multipart/mixed;\n" .
" boundary=\"{$mime_boundary}\"";
$message = $mailbody;
$message = "This is a multi-part message in MIME format.\n\n" .
"--{$mime_boundary}\n" .
"Content-Type: text/html; charset=\"UTF-8\"\n" .
"Content-Transfer-Encoding: 7bit\n\n" .
$message . "\n\n";
// Send the message
$ok = @mail($to, "Indigo Enrollment Form", $message, $headers);
// -- Send Another Message to SENDER
$message = '
Sir / Madam '.$_REQUEST['FirstName'].',
Thank you!
For enrolling. Our represent will call/e-mail you for further communications.
Regards,
'.$domineName.'
';
$to = $_REQUEST['EmailAddress'];
$subject = $domineName." Indigo enrollment - Acknowledgement";
$headers = "MIME-Version: 1.0\r\n";
$headers .= "Content-type: text/html; charset=UTF-8\r\n";
$headers .= "To: ". $to ."\r\n";
//$headers .= "From:indigoconsulting@exemail.com.au \r\n";
$headers .= "From:deepasakri@gmail.com \r\n";
@mail($to, $subject, $message, $headers);
$msg="Your Confirmation is sent to your mail";
?>
My List of Surgeons
|
