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cee lippens
Forum Newbie
Posts: 9 Joined: Tue Sep 29, 2015 11:42 am
Post
by cee lippens » Wed Nov 25, 2015 10:00 am
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;"> </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;"> </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;"> </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;"> </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
Post
by cee lippens » Wed Nov 25, 2015 10:02 am
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>
requinix
Spammer :|
Posts: 6617 Joined: Wed Oct 15, 2008 2:35 am
Location: WA, USA
Post
by requinix » Wed Nov 25, 2015 2:49 pm
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.
Christopher
Site Administrator
Posts: 13596 Joined: Wed Aug 25, 2004 7:54 pm
Location: New York, NY, US
Post
by Christopher » Wed Nov 25, 2015 5:24 pm
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
Post
by cee lippens » Sun Nov 29, 2015 2:44 pm
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;"> </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;"> </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;"> </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;"> </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
Celauran
Moderator
Posts: 6427 Joined: Tue Nov 09, 2010 2:39 pm
Location: Montreal, Canada
Post
by Celauran » Sun Nov 29, 2015 4:26 pm
What sort of errors are you encountering?
Christopher
Site Administrator
Posts: 13596 Joined: Wed Aug 25, 2004 7:54 pm
Location: New York, NY, US
Post
by Christopher » Sun Nov 29, 2015 4:44 pm
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
Post
by cee lippens » Mon Nov 30, 2015 8:10 am
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
Post
by cee lippens » Mon Nov 30, 2015 8:42 am
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
Post
by cee lippens » Mon Nov 30, 2015 8:45 am
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;"> </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;"> </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;"> </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;"> </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;"> </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
Christopher
Site Administrator
Posts: 13596 Joined: Wed Aug 25, 2004 7:54 pm
Location: New York, NY, US
Post
by Christopher » Mon Nov 30, 2015 3:50 pm
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)