php code for a drop down menu for data to be sent to email

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cee lippens
Forum Newbie
Posts: 9
Joined: Tue Sep 29, 2015 11:42 am

form data not being received via email

Post by cee lippens »

hi,
when i submit my form the only data i am receiving in email is the email of the sender, no other data is coming threw!

what's going on?

thank-you
here is the code

Code: Select all

                    <?php
$name=$_POST['name'];
$email=$_POST['email'];
$message=$_POST['message'];
$from = 'From:gavini2@adhdclinic.com';
$to = 'ceelippens2@gmail.com';
$subject = 'adult new patient form';
$body = "firstName: $firstname \n\nlastName: $lastname \n\nEmail: $email \n\nAge: $age \n\nStreet: $street \n\nCity: $city \n\nState: $state\n\nZipcode: $zipcode\n\n cellphone: $cellphone\n\n homephone: $homephone  \n\n Employername: $employername \n\n Workstreet: $workstreet\n\n\ Workcity: $workcity\n\n Workstate: $workstate \n\n Workzipcode: $workzipcode \n\n Workphone: $workusrtel \n\n MartialStatus: $martialStatus \n\n contactname: $contactname \n\n";

if ($_POST['submit']) {
    if (mail ($to, $subject, $body, $from)) { 
        echo '<p>Your message has been sent!</p>';
    } else { 
        echo '<p>Something went wrong, go back and try again!</p>'; 
    }
}

?> 

  <form method="post" name="commentform" action="adlutf.php" autocomplete="on">
<h2 class="text-center"><strong>New Adult ADHD Patient /<br>Family And Insurance Information Form</strong></h2><hr>
		<p class="name">
          <div class="fieldBlock">
<label for="name">First Name</label>
			<input type="fi" name="firstname" id="firstname" placeholder="John " />
            </div>
  <div class="fieldBlock">

		<label for="name">Last Name</label>
			<input type="text" name="Lastname" id="lastname" placeholder=" Doe" />	
 </div>
		</p>
      
    
    
       
<p class="date">
 <div class="fieldBlock">
			<label for="Date">Date of Birth</label>

			<input type="text" name="dob" id="dob" placeholder="12/09/1977" />
           
            </div>
             <div class="fieldBlock">


		<label for="name">Age</label>
			<input type="text" name="age" id="age" placeholder="35" />
            </div>

		</p>

 <div style="clear:both;">&nbsp;</div>
	
            <p class="sex">
            
                  <label><input type="checkbox" id="CheckboxMale" name="driving">Male</label>
                   <label><input type="checkbox" id="CheckboxFemale" name="driving">Female</label>

</p>
<p><strong>*<span style="font-size:14px;color:#C33;">Attenion</span>:</strong> If you do not include a proper home address in the fields below, you're form will be discarded/deleted immediately. Answers such as n/a are not acceptable answers. We need a complete and accurate address to be able to bill you for our services, as well as creating a medical record for you.</p>
<p class="address">
 <div class="fieldBlock">
	<label for="name">Street</label>
			<input type="text" name="street" id="street" placeholder="14 Elm St." />
            </div>
             <div class="fieldBlock">
            	<label for="name">City</label>
			<input type="text" name="city" id="city" placeholder="Novi" />
            </div>
             <div class="fieldBlock">
            <label for="name">State</label>
			<input type="text" name="state" id="state" placeholder="Michigan" />
            </div>
             <div class="fieldBlock">
            <label for="name">Zip Code</label>
            
			<input type="text" name="zipcode" id="zipcode" placeholder="48220" />
            </div>
            </p>
            <div style="clear:both;">&nbsp;</div>
<p class="email">
	<label for="name">Email</label>
			<input type="email" name="email" id="email" placeholder="jondoe@gmail.com" />
            </p>
            <p class="phone">
 <div class="fieldBlock">
	<label for="name">Cell Phone</label>
			<input type="tel" name="usrtel" id="usrtel" placeholder="734-790-7790" />
            </div>
             <div class="fieldBlock">
            	<label for="name">Home Phone</label>
			<input type="tel" name="usrtel" id="usrtel" placeholder="734-790-7790" />
            </div>
            </p>
             <div style="clear:both;">&nbsp;</div>
             
             <p class="employername">
         
<label for="name">Employer Name</label>
			<input type="text" name="employername" id="employername" placeholder="Mega Company " />
            </p>
                         <label for="name">Employer Address</label>  
            <p class="address">
 <div class="fieldBlock">
	<label for="name">Street</label>
			<input type="text" name="workstreet" id="workstreet" placeholder="10005 Main St." />
            </div>
 
             <div class="fieldBlock">
         
            	<label for="name">City</label>
			<input type="text" name="workcity" id="workcity" placeholder="Novi" />
            </div>
             <div class="fieldBlock">
            <label for="name">State</label>
			<input type="text" name="workstate" id="workstate" placeholder="Michigan" />
            </div>
             <div class="fieldBlock">
            <label for="name">Zip Code</label>
            
			<input type="text" name="workzipcode" id="workzipcode" placeholder="48220" />
            </div>
            </p>
            <div style="clear:both;">&nbsp;</div>
            </div>
            <p class="phone">

	<label for="name">Work Phone</label>
			<input type="tel" name="usrtel" id="usrtel" placeholder="734-790-7790" />
          </p>
            <p class="martialstatus">
          	<label for="name">Martial Status</label>
          <select name="Martial Status">
                <option value="double chocolate">Single</option>
                <option value="vanilla">Married</option>
                <option value="strawberry">Divorced</option>
              
        </select>
        </p>
       <p class="name">
       <label for="name">Emergency Contact</label>
          <div class="fieldBlock">
<label for="name">First Name</label>
			<input type="text" name="name" id="name" placeholder="John " />
            </div>
  


  <label><span style="font-size:14px;color:#C33;">Thank-you for filling out and submitting the form.</span></label>

     
    
      
		<p class="submit">

                     <input id="submit" name="submit" type="submit" value="Submit"/>
			

		</p>

	</form>
Last edited by requinix on Wed Nov 25, 2015 2:49 pm, edited 1 time in total.
Reason: use [syntax=php] tags when posting PHP code
cee lippens
Forum Newbie
Posts: 9
Joined: Tue Sep 29, 2015 11:42 am

php code for a drop down menu for data to be sent to email

Post by cee lippens »

how do i write the php code to receive drop down menu data in php via email?

Code: Select all

            <p class="martialstatus">
          	<label for="name">Martial Status</label>
          <select name="Martial Status">
                <option value="double chocolate">Single</option>
                <option value="vanilla">Married</option>
                <option value="strawberry">Divorced</option>
              
        </select>
User avatar
requinix
Spammer :|
Posts: 6617
Joined: Wed Oct 15, 2008 2:35 am
Location: WA, USA

Re: form data not being received via email

Post by requinix »

All those variables you put into the email? You never defined them. You have to define them just like you did for $name and $email.
User avatar
Christopher
Site Administrator
Posts: 13596
Joined: Wed Aug 25, 2004 7:54 pm
Location: New York, NY, US

Re: php code for a drop down menu for data to be sent to ema

Post by Christopher »

There are several step to get from a form submission to receiving an email.

- Create HTML form
- Receive form data
- Validate and filter the data
- Build email body
- Send email

The first step is to put the code below into a <form>. I have cleaned up your HTML a little.

Code: Select all

      <p class="martialstatus">
          <label for="martial_status">Martial Status</label>
          <select name="martial_status" id="martial_status">
                <option value="double chocolate">Single</option>
                <option value="vanilla">Married</option>
                <option value="strawberry">Divorced</option>
           </select>
       </p>
(#10850)
cee lippens
Forum Newbie
Posts: 9
Joined: Tue Sep 29, 2015 11:42 am

Re: php code for a drop down menu for data to be sent to ema

Post by cee lippens »

thanks,
i am asking how to write the php code to send the answer from the drop sown menu..


here's the whole form and php


Code: Select all

                    <?php
$firstname=$_POST['firstname'];
$lastName=$_POST['lastname'];
$age=$_POST['age'];
$street=$_POST['street'];
$city=$_POST['city'];
$state=$_POST['state'];
$zipcode=$_POST['zipcode'];
$email=$_POST['email'];
$cellPhone=$_POST['cellphone'];
$homePhone=$_POST['homephone'];
$employername=$_POST['employername'];
$workstreet=$_POST['workstreet'];
$workcity=$_POST['workcity'];
$workstate=$_POST['workstate'];
$workzipcode=$_POST['workzipcode'];
$workphone=$_POST['workusrtel'];

$martialStatus=$_POST['martialStatus'];
$contactname=$_POST['contactname'];
$workzipcode=$_POST['workzipcode'];

$message=$_POST['message'];
$from = 'From:gavini2@adhdclinic.com';
$to = 'ceelippens2@gmail.com';
$subject = 'adult new patient form';
$body = "firstName: $firstname \n\n lastname: $lastname \n\nEmail: $email \n\nAge: $age \n\nStreet: $street \n\nCity: $city \n\nState: $state\n\nZipcode: $zipcode\n\ncellphone: $cellPhone\n\nhomephone: $homePhone  \n\n Employername: $employername \n\n Workstreet: $workstreet\n\n Workcity: $workcity\n\n Workstate: $workstate \n\n Workzipcode: $workzipcode \n\n workphone: $workusrtel \n\n MartialStatus: $martialStatus \n\n contactname: $contactname \n\n";

if ($_POST['submit']) {
    if (mail ($to, $subject, $phone, $body, $from)) { 
        echo '<p>Your message has been sent!</p>';
    } else { 
        echo '<p>Something went wrong, go back and try again!</p>'; 
    }
}

?> 

  <form method="post" name="commentform" action="adlutf.php" autocomplete="on">
<h2 class="text-center"><strong>New Adult ADHD Patient /<br>Family And Insurance Information Form</strong></h2><hr>
		<p class="name">
          <div class="fieldBlock">
<label for="name">First Name</label>
			<input type="fi" name="firstname" id="firstname" placeholder="John " />
            </div>
  <div class="fieldBlock">

		<label for="name">Last Name</label>
			<input type="text" name="Lastname" id="lastname" placeholder=" Doe" />	
 </div>
		</p>
      
    
    
       
<p class="date">
 <div class="fieldBlock">
			<label for="Date">Date of Birth</label>

			<input type="text" name="dob" id="dob" placeholder="12/09/1977" />
           
            </div>
             <div class="fieldBlock">


		<label for="name">Age</label>
			<input type="text" name="age" id="age" placeholder="35" />
            </div>

		</p>

 <div style="clear:both;">&nbsp;</div>
	
            <p class="sex">
            
                  <label><input type="checkbox" id="CheckboxMale" name="driving">Male</label>
                   <label><input type="checkbox" id="CheckboxFemale" name="driving">Female</label>

</p>
<p><strong>*<span style="font-size:14px;color:#C33;">Attenion</span>:</strong> If you do not include a proper home address in the fields below, you're form will be discarded/deleted immediately. Answers such as n/a are not acceptable answers. We need a complete and accurate address to be able to bill you for our services, as well as creating a medical record for you.</p>
<p class="address">
 <div class="fieldBlock">
	<label for="name">Street</label>
			<input type="text" name="street" id="street" placeholder="14 Elm St." />
            </div>
             <div class="fieldBlock">
            	<label for="name">City</label>
			<input type="text" name="city" id="city" placeholder="Novi" />
            </div>
             <div class="fieldBlock">
            <label for="name">State</label>
			<input type="text" name="state" id="state" placeholder="Michigan" />
            </div>
             <div class="fieldBlock">
            <label for="name">Zip Code</label>
            
			<input type="text" name="zipcode" id="zipcode" placeholder="48220" />
            </div>
            </p>
            <div style="clear:both;">&nbsp;</div>
<p class="email">
	<label for="name">Email</label>
			<input type="email" name="email" id="email" placeholder="jondoe@gmail.com" />
            </p>
            <p class="phone">
 <div class="fieldBlock">
	<label for="name">Cell Phone</label>
			<input type="tel" name="usrtel" id="usrtel" placeholder="734-790-7790" />
            </div>
             <div class="fieldBlock">
            	<label for="name">Home Phone</label>
			<input type="tel" name="usrtel" id="usrtel" placeholder="734-790-7790" />
            </div>
            </p>
             <div style="clear:both;">&nbsp;</div>
             
             <p class="employername">
         
<label for="name">Employer Name</label>
			<input type="text" name="employername" id="employername" placeholder="Mega Company " />
            </p>
                         <label for="name">Employer Address</label>  
            <p class="address">
 <div class="fieldBlock">
	<label for="name">Street</label>
			<input type="text" name="workstreet" id="workstreet" placeholder="10005 Main St." />
            </div>
 
             <div class="fieldBlock">
         
            	<label for="name">City</label>
			<input type="text" name="workcity" id="workcity" placeholder="Novi" />
            </div>
             <div class="fieldBlock">
            <label for="name">State</label>
			<input type="text" name="workstate" id="workstate" placeholder="Michigan" />
            </div>
             <div class="fieldBlock">
            <label for="name">Zip Code</label>
            
			<input type="text" name="workzipcode" id="workzipcode" placeholder="48220" />
            </div>
            </p>
            <div style="clear:both;">&nbsp;</div>
            </div>
            <p class="phone">

	<label for="name">Work Phone</label>
			<input type="tel" name="usrtel" id="usrtel" placeholder="734-790-7790" />
          </p>
            <p class="martialstatus">
          	<label for="name">Martial Status</label>
          <select name="Martial Status">
                <option value="double chocolate">Single</option>
                <option value="vanilla">Married</option>
                <option value="strawberry">Divorced</option>
              
        </select>
        </p>
       <p class="name">
       <label for="name">Emergency Contact</label>
          <div class="fieldBlock">
<label for="name">First Name</label>
			<input type="text" name="name" id="name" placeholder="John " />
            </div>
  


  <label><span style="font-size:14px;color:#C33;">Thank-you for filling out and submitting the form.</span></label>

     
    
      
		<p class="submit">

                     <input id="submit" name="submit" type="submit" value="Submit"/>
			

		</p>

	</form>
Last edited by Celauran on Sun Nov 29, 2015 4:25 pm, edited 1 time in total.
Reason: Please wrap your code in syntax blocks
User avatar
Celauran
Moderator
Posts: 6427
Joined: Tue Nov 09, 2010 2:39 pm
Location: Montreal, Canada

Re: php code for a drop down menu for data to be sent to ema

Post by Celauran »

What sort of errors are you encountering?
User avatar
Christopher
Site Administrator
Posts: 13596
Joined: Wed Aug 25, 2004 7:54 pm
Location: New York, NY, US

Re: php code for a drop down menu for data to be sent to ema

Post by Christopher »

Code: Select all

    if (mail ($to, $subject, $phone, $body, $from)) { 
Take a look at the PHP documentation for the mail() function (http://php.net/manual/en/function.mail.php). The parameters are To, Subject, Body and Headers. The documentation explains how to build headers for From, ReplyTo, CC, etc.
(#10850)
cee lippens
Forum Newbie
Posts: 9
Joined: Tue Sep 29, 2015 11:42 am

Re: php code for a drop down menu for data to be sent to ema

Post by cee lippens »

i am not sure how to write the php for the drop down menu, when an item is selected how is that send via the php with the rest of the body of info to e-mail? also not all the info is being received via email, like lastname does not come through.
thanks
cee lippens
Forum Newbie
Posts: 9
Joined: Tue Sep 29, 2015 11:42 am

Re: php code for a drop down menu for data to be sent to ema

Post by cee lippens »

hi Celauran,

i was receiving most of the data, but am not not receiving any mail when i hit submit? now?????? help :-)
cee lippens
Forum Newbie
Posts: 9
Joined: Tue Sep 29, 2015 11:42 am

Re: form data not being received via email

Post by cee lippens »

below is what i added,now i am not receiving any email at all when i hit submit

Code: Select all

 <?php
$firstname=$_POST['firstname'];
$lastName=$_POST['lastname'];
$checkboxm=$_POST['checkboxm'];
$checkboxf=$_POST['checkboxf'];
$dob=$_POST['dob'];
$age=$_POST['age'];
$street=$_POST['street'];
$city=$_POST['city'];
$state=$_POST['state'];
$zipcode=$_POST['zipcode'];
$email=$_POST['email'];
$cellPhone=$_POST['cellphone'];
$homePhone=$_POST['homephone'];
$employername=$_POST['employername'];
$workstreet=$_POST['workstreet'];
$workcity=$_POST['workcity'];
$workstate=$_POST['workstate'];
$workzipcode=$_POST['workzipcode'];
$workusrtel=$_POST['workusrtel'];
$martialStatus=$_POST['martialStatus'];
$contactname=$_POST['contactname'];
$econtactphone=$_POST['econtactphone'];
$EmergencyRelationship=$_POST['EmergencyRelationship'];
$referredname =$_POST['referredname '];
$date_today =$_POST['date_today'];
$pharmacyname =$_POST['pharmacyname'];
$pharmacyaddress =$_POST['pharmacyaddress'];
$phonepharmacy =$_POST['phonepharmacy'];

$message=$_POST['message'];
$from = 'From:gavini2@adhdclinic.com';
$to = 'ceelippens2@gmail.com';
$subject = 'adult new patient form';
$body = "firstName: $firstname \n\n lastname: $lastname \n\ncheckboxm: $checkboxm \n\ncheckboxf: $checkboxf\n\nEmail: $email \n\ndob: $dob \n\nAge: $age \n\nStreet: $street \n\nCity: $city \n\nState: $state\n\nZipcode: $zipcode\n\ncellphone: $cellPhone\n\nhomephone: $homePhone  \n\n Employername: $employername \n\n Workstreet: $workstreet\n\n Workcity: $workcity\n\n Workstate: $workstate \n\n Workzipcode: $workzipcode \n\n workphone: $workusrtel \n\n MartialStatus: $martialStatus \n\n contactname: $contactname \n\n econtactphone: $econtactphone \n\n EmergencyRelationship: $EmergencyRelationship \n\n referredname: $referredname \n\n date_today: $date_today\n\n pharmacyname: $pharmacynamen\n  pharmacyaddress: $pharmacyaddress n\n phonepharmacy: $phonepharmacy n\n";

if ($_POST['submit']) {
    if (mail ($to, $subject, $body, $from)) { 
        echo '<p>Your message has been sent!</p>';
    } else { 
        echo '<p>Something went wrong, go back and try again!</p>'; 
    }
}

?> 

    
           <form method="post" name="commentform" action="adlutf.php" autocomplete="on">
<h2 class="text-center"><strong>New Adult ADHD Patient /<br>Family And Insurance Information Form</strong></h2><hr>
		<p class="name">
          <div class="fieldBlock">
<label for="name">First Name</label>
			<input type="text" name="firstname" id="firstname" placeholder="John " />
            </div>
  <div class="fieldBlock">

		<label for="name">Last Name</label>
			<input type="text" name="lastname" id="lastname" placeholder=" Doe" />	
 </div>
		</p>
      
    
    
       
<p class="date">
 <div class="fieldBlock">
			<label for="Date">Date of Birth</label>

			<input type="text" name="dob" id="dob" placeholder="12/09/1977" />
           
            </div>
             <div class="fieldBlock">


		<label for="name">Age</label>
			<input type="text" name="age" id="age" placeholder="35" />
            </div>

		</p>

 <div style="clear:both;">&nbsp;</div>
	
            <p class="sex">
            
                  <label><input type="checkbox" id="Checkboxm" name="driving">Male</label>
                   <label><input type="checkbox" id="Checkboxf" name="driving">Female</label>

</p>
<p><strong>*<span style="font-size:14px;color:#C33;">Attenion</span>:</strong> If you do not include a proper home address in the fields below, you're form will be discarded/deleted immediately. Answers such as n/a are not acceptable answers. We need a complete and accurate address to be able to bill you for our services, as well as creating a medical record for you.</p>
<p class="address">
 <div class="fieldBlock">
	<label for="name">Street</label>
			<input type="text" name="street" id="street" placeholder="14 Elm St." />
            </div>
             <div class="fieldBlock">
            	<label for="name">City</label>
			<input type="text" name="city" id="city" placeholder="Novi" />
            </div>
             <div class="fieldBlock">
            <label for="name">State</label>
			<input type="text" name="state" id="state" placeholder="Michigan" />
            </div>
             <div class="fieldBlock">
            <label for="name">Zip Code</label>
            
			<input type="text" name="zipcode" id="zipcode" placeholder="48220" />
            </div>
            </p>
            <div style="clear:both;">&nbsp;</div>
<p class="email">
	<label for="name">Email</label>
			<input type="email" name="email" id="email" placeholder="jondoe@gmail.com" />
            </p>
            <p class="phone">
 <div class="fieldBlock">
	<label for="name">Cell Phone</label>
			<input type="text" name="cellphone" id="cellphone" placeholder="734-790-7790" />
            </div>
             <div class="fieldBlock">
            	<label for="name">Home Phone</label>
			<input type="text" name="homephone" id="homephone" placeholder="734-790-7790" />
            </div>
            </p>
             <div style="clear:both;">&nbsp;</div>
             
             <p class="employername">
         
<label for="name">Employer Name</label>
			<input type="text" name="employername" id="employername" placeholder="Mega Company " />
            </p>
                         <label for="name">Employer Address</label>  
            <p class="address">
 <div class="fieldBlock">
	<label for="name">Street</label>
			<input type="text" name="workstreet" id="workstreet" placeholder="10005 Main St." />
            </div>
 
             <div class="fieldBlock">
         
            	<label for="name">City</label>
			<input type="text" name="workcity" id="workcity" placeholder="Novi" />
            </div>
             <div class="fieldBlock">
            <label for="name">State</label>
			<input type="text" name="workstate" id="workstate" placeholder="Michigan" />
            </div>
             <div class="fieldBlock">
            <label for="name">Zip Code</label>
            
			<input type="text" name="workzipcode" id="workzipcode" placeholder="48220" />
            </div>
            </p>
            <div style="clear:both;">&nbsp;</div>
            </div>
            <p class="phone">

	<label for="name">Work Phone</label>
			<input type="tel" name="workusrtel" id="workusrtel" placeholder="734-790-7790" />
          </p>
            <p class="martialstatus">
          	<label for="name">Martial Status</label>
          <select name="Martial Status">
                <option value="double chocolate">Single</option>
                <option value="vanilla">Married</option>
                <option value="strawberry">Divorced</option>
              
        </select>
        </p>
       <p class="name">
       <label for="name">Emergency Contact</label>
          <div class="fieldBlock">
<label for="name">Full Name</label>
			<input type="text" name="contactname" id="contactname" placeholder="John " />
            </div>
  

  <div class="fieldBlock">

		<label for="name">Last Name</label>
			<input type="text" name="name" id="name" placeholder=" Doe" />	
 </div>
		</p>
        <div style="clear:both;">&nbsp;</div>
        <p class="phone">

	<label for="name">Emergency Contact Phone</label>
			<input type="tel" name="econtactphone" id="econtactphone" placeholder="734-790-7790" />
          </p>
            <p class="EmergencyRelationship">
        
          	<label for="name">Emergency Contact Relationship</label>
          <select name="Martial Status">
                <option value="double chocolate">Spouse</option>
                 <option value="strawberry">Partner</option>
                <option value="vanilla">Mother</option>
                <option value="strawberry">Father</option>
                 <option value="strawberry">Sister</option>
                  <option value="strawberry">Brother</option>
                     <option value="strawberry">GrandParent</option>
                       <option value="strawberry">Friend</option>
                        <option value="strawberry">Other</option>
                        
              
        </select>
        </p>
   <p class="referred ">
            <label for="name">Who referred you to our office?</label>
            
			<input type="text" name="referredname" id="referredname" placeholder="Jane Doe" />
        
            </p>
      	<p class="submit">

                     <input id="submit" name="submit" type="submit" value="Submit"/>
			

		</p>

	</form>
Last edited by requinix on Mon Nov 30, 2015 2:47 pm, edited 1 time in total.
Reason: use [syntax=php] tags when posting PHP code
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Christopher
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Joined: Wed Aug 25, 2004 7:54 pm
Location: New York, NY, US

Re: php code for a drop down menu for data to be sent to ema

Post by Christopher »

cee lippens wrote:i am not sure how to write the php for the drop down menu, when an item is selected how is that send via the php with the rest of the body of info to e-mail?
When you set the name of a HTML form element, that name is used to put the value in the $_POST array.

Code: Select all

<input type="checkbox" name="foo" value="bar">
// or
<select name="foo">
<option value="bar">
<option value="baz">
</select>
// both are put into
$foo = $_POST['foo'];
cee lippens wrote:also not all the info is being received via email, like lastname does not come through.
If the are not in the message body, then you are not putting them into $body, are using the wrong variable, or have the wrong name for the $_POST element.
(#10850)
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