/** CONFIGURE THESE VARIABLES BETWEEN HERE **/
$your_address = "rsdinfo@becon.org";
/** AND HERE **/
// GENERAL INFORMATION
$msg = "";
$msg .= "GENERAL INFORMATION\n";
$msg .= "\n";
$msg .= "1. What is your age? " . $_POST['age'] . "\n";
$msg .= "2. Are you male or female? " . $_POST['sex'] . "\n";
$msg .= "3. How long have you had RSD/CRPS? " . $_POST['how_long'] . "\n";
if ($_POST['diagnosis'] == 'No Diagnosis') {
$msg .= "4. Please state time from onset (start of disease) until diagnosis of RSD/CRPS? No diagnosis.\n";
} else {
$msg .= "4. Please state time from onset (start of disease) until diagnosis of RSD/CRPS? " . $_POST['diagnosis_years'] . " years, " . $_POST['diagnosis_months'] . " months, " . $_POST['diagnosis_weeks'] . " weeks.\n";
}
if ($_POST['treatment'] == 'No Treatment') {
$msg .= "5. Please state time from onset (start of disease) until treatment for your RSD/CRPS? No treatment.\n";
} else {
$msg .= "5. Please state time from onset (start of disease) until treatment for your RSD/CRPS? Time until treatment: " . $_POST['treatment_years'] . " years, " . $_POST['treatment_months'] . " months, " . $_POST['treatment_weeks'] . " weeks.\n";
}
$msg .= "6. FOR CANADIANS ONLY: If you are Canadian, please give your location (nearest city): " . $_POST['nearest_city'] . "\n";
// PARC REQUEST FORM
$msg .= "\n";
$msg .= "\nPARC REQUEST FORM\n";
$msg .= "\n";
$msg .= "Name: " . $_POST['name'] . "\n";
$msg .= "Address: " . $_POST['address'] . "\n";
$msg .= "City: " . $_POST['city'] . "\n";
$msg .= "Province/State: " . $_POST['provstate'] . "\n";
$msg .= "ZIP/Postal Code: " . $_POST['zippostal'] . "\n";
$msg .= "Country: " . $_POST['country'] . "\n";
$msg .= "Phone Number: " . $_POST['phone_number'] . "\n\n";
$msg .= "\nYES/NO OPTIONS\n";
$msg .= "\n";
if (isset($_POST['membersip_info'])) $msg .= "How can I become a PARC Member and receive my free gift?\n";
if (isset($_POST['send_info'])) $msg .= "Please send RSD/CRPS information.\n";
if (isset($_POST['subscribe_parc_pearl'])) $msg .= "I want to subscribe to your newsletter\n";
if (isset($_POST['parc_projects'])) $msg .= "PARC Projects for 2003\n";
if (isset($_POST['donation'])) $msg .= "I would like to make a donation\n";
if (isset($_POST['question'])) $msg .= "I have a specific question about RSD/CRPS\n";
if (isset($_POST['sharestory'])) $msg .= "I would like to share my story\n";
$msg .= "\n\nCOMMENTS / SUGGESTIONS\n";
$msg .= "\n";
$msg .= $_POST['comments_and_suggestions'] . "\n\n";
// ok, message has been created. send it to the email address.
mail($your_address, "Website Message", $msg, "From: <" . $_POST['email'] . ">\r\n" . "X-Mailer: PHP/" . phpversion()) or die("Erorr sending message! ");
?>
Thank
you very much for your message!
Your
message is displayed below:
echo $msg; ?> |