form.htm
<form id="form1" name="form1" method="post" action="send1.php">
<table width="602" border="0" align="left" cellpadding="0" cellspacing="0">
<tr>
<td width="10"><img src="images/clear.gif" width="10" height="1" /></td>
<td width="197" class="subtitulo"></td>
<td width="18" class="subtitulo"> </td>
<td width="377" class="subtitulo">Formulario de Registro:</td>
</tr>
<tr>
<td> </td>
<td class="subtitulo"></td>
<td class="subtitulo"> </td>
<td class="subtitulo"> </td>
</tr>
<tr>
<td> </td>
<td rowspan="6" valign="top" class="texto"><br /></td>
<td class="texto"> </td>
<td rowspan="6" valign="top" class="texto"><table width="100%" border="0" cellspacing="0" cellpadding="0">
<tr>
<td width="36%">Nombre del Paciente: </td>
<td width="64%"><input name="nombre" type="text" id="nombre" /></td>
</tr>
<tr>
<td>Dirección:</td>
<td><input name="direccion" type="text" id="direccion" /></td>
</tr>
<tr>
<td>Distrito:</td>
<td><input name="distrito" type="text" id="distrito" /></td>
</tr>
<tr>
<td>Telefono:</td>
<td><input name="telefono" type="text" id="telefono" value="" /></td>
</tr>
<tr>
<td>E-mail:</td>
<td><input name="mail" type="text" id="mail" /></td>
</tr>
<tr>
<td>Botica ó Farmacia </td>
<td><input name="botica" type="text" id="botica" /></td>
</tr>
<tr>
<td>Donde Adquirió OSEOLEN: </td>
<td> </td>
</tr>
<tr>
<td>Distrito:</td>
<td><input name="distrito2" type="text" id="distrito2" /></td>
</tr>
<tr>
<td>Doctor(a) que lo recetó: </td>
<td><input name="doctor" type="text" id="doctor" /></td>
</tr>
<tr>
<td>Diagnostico:</td>
<td> </td>
</tr>
<tr>
<td valign="top"> </td>
<td><table width="100%" border="0" cellspacing="0" cellpadding="0">
<tr>
<td width="8%"><input name="radio" type="radio" value="radio" /></td>
<td width="68%">Osteopenia</td>
<td width="24%"> </td>
</tr>
<tr>
<td><input name="radio1" type="radio" value="radio1" /></td>
<td>Osteoporosis</td>
<td> </td>
</tr>
</table></td>
</tr>
<tr>
<td> </td>
<td> </td>
</tr>
<tr>
<td> </td>
<td><input type="submit" name="Submit" value="enviar" />
<input type="reset" name="Submit2" value="borrar" /></td>
</tr>
</table></td>
</tr>
<tr>
<td> </td>
<td class="texto"> </td>
</tr>
<tr>
<td> </td>
<td class="texto"> </td>
</tr>
<tr>
<td> </td>
<td class="texto"> </td>
</tr>
<tr>
<td> </td>
<td class="texto"> </td>
</tr>
<tr>
<td> </td>
<td valign="middle"> </td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
</table>
</form> </td>
php:
send1.php
<?php
// get posted data into local variables
$EmailFrom = "[email protected]";
$EmailTo = "[email protected]";
$Subject = "Envio de Formulario";
$nombre = Trim(stripslashes($_POST['nombre']));
$direccion = Trim(stripslashes($_POST['direccion']));
$distrito = Trim(stripslashes($_POST['distrito']));
$telefono = Trim(stripslashes($_POST['telefono']));
$mail = Trim(stripslashes($_POST['mail']));
$botica = Trim(stripslashes($_POST['botica']));
$distrito = Trim(stripslashes($_POST['distrito2']));
$doctor = Trim(stripslashes($_POST['doctor']));
//$radio = Trim(stripslashes($_POST['radio']));
//$radio1 = Trim(stripslashes($_POST['radio1']));
// validation
$validationOK=true;
if (Trim($nombre)=="") $validationOK=false;
if (Trim($direccion)=="") $validationOK=false;
if (Trim($distrito)=="") $validationOK=false;
if (Trim($telefono)=="") $validationOK=false;
if (Trim($mail)=="") $validationOK=false;
if (Trim($botica)=="") $validationOK=false;
if (Trim($distrito2)=="") $validationOK=false;
if (Trim($doctor)=="") $validationOK=false;
//if (Trim($radio)=="") $validationOK=false;
//if (Trim($radio1)=="") $validationOK=false;
if (!$validationOK) {
print "<meta http-equiv=\"refresh\" content=\"0;URL=error.htm\">";
exit;
}
// prepare email body text
$Body = "";
$Body .= "nombre: ";
$Body .= $nombre;
$Body .= "\n";
$Body .= "direccion: ";
$Body .= $direccion;
$Body .= "\n";
$Body .= "distrito: ";
$Body .= $distrito;
$Body .= "\n";
$Body .= "telefono: ";
$Body .= $telefono;
$Body .= "\n";
$Body .= "mail: ";
$Body .= $mail;
$Body .= "\n";
$Body .= "Botica ó Farmacia: ";
$Body .= $botica;
$Body .= "\n";
$Body .= "Donde Adquirió OSEOLEN: ";
$Body .= "\n";
$Body .= "distrito: ";
$Body .= $distrito2;
$Body .= "\n";
$Body .= "Doctor(a) que lo recetó: ";
$Body .= $doctor;
$Body .= "\n";
//$Body .= "radio: ";
//$Body .= $radio;
//$Body .= "\n";
//$Body .= "radio1: ";
//$Body .= $radio1;
//$Body .= "\n";
// send email
$success = mail($EmailTo, $Subject, $Body, "From: <$EmailFrom>");
// redirect to success page
if ($success){
print "<meta http-equiv=\"refresh\" content=\"0;URL=form_promocion.htm\">";
}
//else{
//print "<meta http-equiv=\"refresh\" content=\"0;URL=gracias.htm\">";
//}
?>