<%@ LANGUAGE="VBScript" %> <% ' On Error Resume Next ' Classsic ASP pages created by Andre F Bruton ' E-mail: andre@bruton.co.za ' Date: 2008/01/19 namep = SQLEncode(Request("namep")) email = SQLEncode(Request("email")) intcode = SQLEncode(Request("intcode")) areacode = SQLEncode(Request("areacode")) phoneno = SQLEncode(Request("phoneno")) mobileintcode = SQLEncode(Request("mobileintcode")) mobile = SQLEncode(Request("mobile")) city = SQLEncode(Request("city")) state = SQLEncode(Request("state")) address = SQLEncode(Request("address")) comments = SQLEncode(Request("comments")) patientname = SQLEncode(Request("patientname")) patientemail = SQLEncode(Request("patientemail")) patientintcode = SQLEncode(Request("patientintcode")) patientareacode = SQLEncode(Request("patientareacode")) patientphone = SQLEncode(Request("patientphone")) patientmobileintcode = SQLEncode(Request("patientmobileintcode")) patientmobileno = SQLEncode(Request("patientmobileno")) patientcity = SQLEncode(Request("patientcity")) patientstate = SQLEncode(Request("patientstate")) patientaddress = SQLEncode(Request("patientaddress")) patientcomments = SQLEncode(Request("patientcomments")) status = SQLEncode(Request("status")) lookfor = SQLEncode(Request("lookfor")) recaptcha_challenge_field = Request("recaptcha_challenge_field") recaptcha_response_field = Request("recaptcha_response_field") recaptcha_private_key = "6LdTeLoSAAAAAC75m5T09Gjs9NIX-Naey4Al36My" recaptcha_public_key = "6LdTeLoSAAAAAOyq4XHU7Fx9ir_AGRUwHRFwdoow" browser = Request.ServerVariables("HTTP_USER_AGENT") ip = Request.ServerVariables("REMOTE_HOST") %> Refer Patient India,Cost Refer Patient Mumbai India,Refer Nri Patients
 
 
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Refer A Patient in India


Overview


Are you a General Practitioner, a Doctor or are you involved in the healthcare service industry in your country? Do you want to refer a patient treatment or surgery to India

If Yes, Please fill the given form and send us immediately : -




Your Details


    (*) Fields are mandatory

Your Name * :

 

Gender * :

  Male Female

Your E-Mail * :

 

Telephone * :

  Intl Code  

Area Code

Mobile * :

  Intl Code  

City * :

 

State * :

 

Country * :

 

Address * :

 

Your Message * :

 
     

Patients Details


    (*) Fields are mandatory

Patient Name * :

 

Gender:

  Male Female

Patient E-Mail * :

 

Telephone :

  Intl Code  

Area Code

Mobile :

  Intl Code  

City:

 

State:

 

Country * :

 

Address:

 

Message * :

 

Clinical Status of the patient *:

 

Treatment Looking for * :

 
    <%=recaptcha_challenge_writer(recaptcha_public_key)%>
   
     
<% cTemp = recaptcha_confirm(recaptcha_private_key, recaptcha_challenge_field, recaptcha_response_field) If cTemp <> "" Then %>

An error occured with the recapture wording. Please try again. The error was Invalid Captcha Code


<% Else %> <% getemail=trim(Request.Form("email")) Dim iMsg Dim iConf Dim Flds Dim strHTML Dim strSmartHost dim email email=Request.Form("email") Const cdoSendUsingPort = 1 StrSmartHost = "mail.wecareindia.com" set iMsg = CreateObject("CDO.Message") set iConf = CreateObject("CDO.Configuration") dim strmess strmess="Query Form from We Care india
" strmess=strmess & "
Contact Message
" strmess=strmess & "
Details of "& Request.Form("namep") & " 
" strmess=strmess & "
Your Name :     "& Request.Form("namep") & "" strmess=strmess & "
Gender :     "& Request.Form("gender") & "" strmess=strmess & "
Email :     "& email strmess=strmess & "
Telephone Number :     "& Request.Form("intcode") & "" strmess=strmess & "   -   "& Request.Form("areacode") & "" strmess=strmess & "   -   "& Request.Form("phoneno") & "" strmess=strmess & "
Mobile Number :     "& Request.Form("mobileintcode") & "" strmess=strmess & "   -   "& Request.Form("mobile") & "" strmess=strmess & "
City :     "& Request.Form("city") & "" strmess=strmess & "
State :     "& Request.Form("state") & "" strmess=strmess & "
Country :     "& Request.Form("country") & "" strmess=strmess & "
Address :     "& Request.Form("address") & "" strmess=strmess & "
Your Message :     "& Request.Form("comments") & "

" strmess=strmess & "
"& Request.Form("patientname") & "  Details
" strmess=strmess & "
Name :     "& Request.Form("patientname") & "" strmess=strmess & "
Gender :     "& Request.Form("patientgender") & "" strmess=strmess & "
Email :     "& Request.Form("patientemail") & "" strmess=strmess & "
Telephone Number :     "& Request.Form("patientintcode") & "" strmess=strmess & "   -   "& Request.Form("patientareacode") & "" strmess=strmess & "   -   "& Request.Form("patientphone") & "" strmess=strmess & "
Mobile Number :     "& Request.Form("patientmobileintcode") & "" strmess=strmess & "   -   "& Request.Form("patientmobileno") & "" strmess=strmess & "
City :     "& Request.Form("patientcity") & "" strmess=strmess & "
State :     "& Request.Form("patientstate") & "" strmess=strmess & "
Country :     "& Request.Form("patientcountry") & "" strmess=strmess & "
Address :     "& Request.Form("patientaddress") & "" strmess=strmess & "
Your Message :     "& Request.Form("patientcomments") & "" strmess=strmess & "
Clinical Status of the patient :     "& Request.Form("status") & "" strmess=strmess & "
Treatment Looking for :     "& Request.Form("lookfor") & "" Set Flds = iConf.Fields With Flds .Item("http://schemas.microsoft.com/cdo/configuration/sendusing") = cdoSendUsingPort .Item("http://schemas.microsoft.com/cdo/configuration/smtpserver") = strSmartHost .Item("http://schemas.microsoft.com/cdo/configuration/sendusername") = "info@wecareindia.com" .Item("http://schemas.microsoft.com/cdo/configuration/sendpassword") = "info@123" .Item("http://schemas.microsoft.com/cdo/configuration/smtpconnectiontimeout") = 10 .Item("http://schemas.microsoft.com/cdo/configuration/smtpserverport") = 26 .Item("http://schemas.microsoft.com/cdo/configuration/smtpauthenticate") = 1 .Item("http://schemas.microsoft.com/cdo/configuration/smtpserverpickupdirectory")="C:\Inetpub\mailroot\Pickup" .Update End With ' apply the settings to the message With iMsg Set .Configuration = iConf .To = "info@wecareindia.com" .BCC = "sumit@thewebnsoft.in" '.From = getemail .From = email '.From = "info.wecareindia@gmail.com" .Subject = "Query Form from We Care India" .HTMLBody = strmess .Send End With ' cleanup of variables Set iMsg = Nothing Set iConf = Nothing Set Flds = Nothing Response.Redirect("thanks.htm") %> <% End If %> <% ' The code below supplied by Mark Short ' returns string the can be written where you would like the reCAPTCHA challenged placed on your page function recaptcha_challenge_writer(publickey) recaptcha_challenge_writer = "" & _ "" & _ "" end function function recaptcha_confirm(privkey,rechallenge,reresponse) ' Test the captcha field Dim VarString VarString = _ "privatekey=" & privkey & _ "&remoteip=" & Request.ServerVariables("REMOTE_ADDR") & _ "&challenge=" & rechallenge & _ "&response=" & reresponse Dim objXmlHttp Set objXmlHttp = Server.CreateObject("Msxml2.ServerXMLHTTP") objXmlHttp.open "POST", "http://api-verify.recaptcha.net/verify", False objXmlHttp.setRequestHeader "Content-Type", "application/x-www-form-urlencoded" objXmlHttp.send VarString Dim ResponseString ResponseString = split(objXmlHttp.responseText, vblf) Set objXmlHttp = Nothing if ResponseString(0) = "true" then ' They answered correctly recaptcha_confirm = "" else ' They answered incorrectly recaptcha_confirm = ResponseString(1) end if end function %>




Refer A Patient in India

For more information, medical assessment and medical quote
send your detailed medical history and medical reports
as email attachment to
Email : - info@wecareindia.com
Call: +91 9029304141 (10 am. To 8 pm. IST)
(Only for international patients seeking treatment in India)


Only in wecareindia.com
Send Response
 
         
         
         
  
For a detailed evaluation send patient's medical reports / X rays / doctors notes to info@wecareindia.com
 
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