<% if (Request.ServerVariables("HTTP_METHOD")) = "POST" then nm = Request.Form("txtName") degree = Request.Form("txtDegree") special = Request.Form("txtSpecial") hos = Request.Form("txtHospital") address = Request.Form("txtAddress") contact = Request.Form("txtContact") email = Request.Form("txtEmail") payment = Request.Form("txtPayment") bank = Request.Form("txtBank") branch = Request.Form("txtBranch") cheque = Request.Form("txtCheque") chdate = Request.Form("txtDate") set pMail=Server.CreateObject("CDONTS.NewMail") pMail.mailformat =cdomailformatmime pMail.From=email pMail.To="rijomc@ammascan.com" pMail.Subject="Online Registration Details" str= " Online Registration:: " str= str & " Name : " & nm & vbcrlf str= str & " Degree: " & degree & vbcrlf str= str & " Hospital or Organization : " & hos & vbcrlf str= str & " Communication Address : " & address & vbcrlf str = str & " Contact No. :" & contact & vbcrlf str = str & " Email :" & email & vbcrlf str = str & " Payment Details :" & payment & vbcrlf str = str & " Name of the Bank :" & bank & vbcrlf str = str & " Branch :" & branch & vbcrlf str = str & " Cheque/DD No. :" & cheque & vbcrlf str = str & " Date :" & chdate & vbcrlf pMail.Body = str pMail.Send Set pMail= Nothing response.redirect("thanks.html") end if%>
Online Registration For Doctors
Name
Degree
Specialty
Hospital or Organization
Communication Address
Contact No.
Email Address
Payment Details
Name of The Bank
Branch
Cheque/DD No.
Date
Jewel Arcade Building, Layam Road,KOCHI.
Ph. 0484 2350294
Dr.Rijo Mathew Mob: 98460 76204