*"; } } if(!$error){ if(checkEmail($_POST["email"]) == true){ if(md5($_POST["verif_box"]).'a4xn' == $_COOKIE['tntcon']){ $content = "Health professional referral from the mindset website:\n\n"; $content .= "====================: \n\n"; $content .= "DETAILS OF THE CLIENT: \n\n"; $content .= "====================: \n\n"; $content .= "Name: " . $_POST["name"] . "\n"; $content .= "Phone: " . $_POST["phone"] . "\n"; $content .= "Email: " . $_POST["email"] . "\n"; $content .= "Address: " . $_POST["address"] . "\n"; $content .= "DOB: " . $_POST["dob"] . "\n"; $content .= "NHI: " . $_POST["NHI"] . "\n"; $content .= "-------------------------: \n\n"; $content .= "Presenting problem:\n " . $_POST["problem"] . "\n"; $content .= "-------------------------: \n\n"; $content .= "Safety concerns:\n " . $_POST["safety"] . "\n"; $content .= "-------------------------: \n\n"; $content .= "Current medications:\n " . $_POST["medications"] . "\n"; $content .= "-------------------------: \n\n"; $content .= "Other services:\n " . $_POST["oservices"] . "\n"; $content .= "====================: \n\n"; $content .= "DETAILS OF THE HEALTH PROFESSIONAL: \n\n"; $content .= "====================: \n\n"; $content .= "Name: " . $_POST["namep"] . "\n"; $content .= "Occupation: " . $_POST["occupation"] . "\n"; $content .= "Company: " . $_POST["company"] . "\n"; $content .= "Phone: " . $_POST["phonep"] . "\n"; $content .= "Email: " . $_POST["emailp"] . "\n"; mail("info@mindsetpsychology.co.nz", 'Health professional referral from the mindset website', $_SERVER['REMOTE_ADDR']."\n\n".$content, "From: " . $_POST["email"]); setcookie('tntcon',''); for($counter=0;$counter Untitled Document
Self referral form
Health Professional referral form
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Health Professional Referral Form

Please check your input in the fields marked *"; } ?>

 

Details of the Client

 Details of the Health Professional
name: name:
date of birth: occupation:
NHI: company:
email: email:
phone: phone:
address:
presenting a problem:  
safety concerns:  
current medications:  
other services involved:  
anti-spam verification image:

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