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Enquiry Form

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<% IF request("verificationCode") <> "" AND Request("verificationCode") = session("verificationCode") THEN 'proposal name = Request.form("name") provider = Request.form("provider") add1 = Request.form("add1") add2 = Request.form("add2") cont = Request.form("country") pcode = Request.form("postal_code") phone = Request.form("phone") fax = Request.form("fax") email = Request.form("email") special = Request.form("special") nvisits = Request.form("no_visits") npatient = Request.form("no_inpatients") abilling = Request.form("average_billing") insurance = Request.form("insurance") sbill = Request.form("super_bill") mrecords = Request.form("medical_records") practice = Request.form("practice") emr = Request.form("emr") loc = Request.form("location") hours = Request.form("hours") requ = Request.form("requirement") when = Request.form("when1") stage = Request.form("stage") volume = Request.form("volume") infor = Request.form("information") dline = Request.form("deadline") dim strbody strBody = strBody&vbcrlf&"Business Entity :"&" "&name strBody = strBody&vbcrlf&"Provider :"&" "&provider strBody = strBody&vbcrlf&"Address :"&" "&add1 strBody = strBody&vbcrlf&"Country :"&" "&cont strbody = strbody&vbcrlf&"Postal Code :"&" "&pcode strbody = strbody&vbcrlf&"Phone :"&" "&phone strbody = strbody&vbcrlf&"Fax :"&" "&fax strbody = strbody&vbcrlf&"Email :"&" "&email strbody = strbody&vbcrlf&"Special Type :"&" "&special strbody = strbody&vbcrlf&"Number of Visits/Day (Outpatient) :"&" "&nvisits strbody = strbody&vbcrlf&"Number of Inpatients :"&" "&npatient strbody = strbody&vbcrlf&" Average billing value per week :"&" "&abilling strbody = strbody&vbcrlf&" Any capitated agreement with the insurance :"&" "&insurance strbody = strbody&vbcrlf&" Super bill :"&" "&sbill strbody = strbody&vbcrlf&" Medical Records :"&" "&mrecords strbody = strbody&vbcrlf&" Practice Management software :"&" "&practice strbody = strbody&vbcrlf&" EMR :"&" "&emr strbody = strbody&vbcrlf&" Location :"&" "&loc strbody = strbody&vbcrlf&" Hours of Operations :"&" "&hours strbody = strbody&vbcrlf&" Please give us a description of your requirements :"&" "&requ strbody = strbody&vbcrlf&" When do you want to start your project ?"&" "&when strbody = strbody&vbcrlf&" At what stage are you in the outsourcing process :"&" "&stage strbody = strbody&vbcrlf&" Volume of work :"&" "&volume strbody = strbody&vbcrlf&" Do you have any concerns or additional information :"&" "&infor strbody = strbody&vbcrlf&" Do you have a deadline to complete the project :"&" "&dline sch = "http://schemas.microsoft.com/cdo/configuration/" Set cdoConfig = Server.CreateObject("CDO.Configuration") With cdoConfig.Fields .Item(sch & "sendusing") = 2 ' cdoSendUsingPort .Item(sch & "smtpserver") = "127.0.0.1" .update End With Set cdoMessage = Server.CreateObject("CDO.Message") With cdoMessage Set .Configuration = cdoConfig .From = email .To = "sathya@techindia.com" .Subject = "Medical Billing - Enquiry Form" .TextBody = strBody .Send End With Set cdoMessage = Nothing Set cdoConfig = Nothing Response.Redirect "index.html" session("verificationCode") = "" ELSE %>
*  Business Entity :   ">
*  Provider :   ">
*  Address :   ">
">
*  Country :   ">
    Postal Code :   ">
*  Phone :   ">
    Fax :   ">
*  Email Address :   ">
*  Special Type :   ">
*  Number of Visits/Day (Outpatient) :   ">
*  Number of Inpatients :   ">
*  Average billing value per week :   ">
*  Any capitated agreement with the insurance :   ">
*  Super bill :   ">
*   Medical records :   ">
*   Practice Management software :   ">
*   EMR :   ">
*   Location :   ">
    Hours of Operations :   ">
    Please give us a description of your
    requirements  
    When do you want to start your project ?  
    At what stage are you in the outsourcing
    process ?  
    Volume of work   ">
    Do you have any concerns or additional
    information you would like to mention? 
    Do you have a deadline to complete the
    project ?
    If yes, when ?  
Verify Verify Code
<% END IF %>