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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 iMsgDim iConfDim FldsDim strHTMLDim strSmartHostdim emailemail=Request.Form("email")Const cdoSendUsingPort = 1StrSmartHost = "mail.wecareindia.com"set iMsg = CreateObject("CDO.Message")set iConf = CreateObject("CDO.Configuration")dim strmessstrmess="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 :     "& emailstrmess=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.FieldsWith 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".UpdateEnd With' apply the settings to the messageWith iMsgSet .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.SendEnd With' cleanup of variablesSet iMsg = NothingSet iConf = NothingSet Flds = NothingResponse.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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This information is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient.
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