WellNet Healthcare (424) -- WellNet Healthcare OptIn (252)

Visual Data Systems

contact - Wellnet Health Care Contact Us Form

FormID: 340 AccountID: 252

MOBILE LEGACY Contents for config-contact.php file:
<?php $AccountID = 252; $formid = 340; $pageTitle = 'WellNet Healthcare: contact us to request a meeting or more info'; $pageHeader = 'Contact Us For More Information'; $introText = '<p>To request a demo or get more information, thank you for completing the form below and a member of our team will contact you shortly. </p>'; $contactblock = "<li><label for='FirstName' class='inline'>First Name:</label> <input id='FirstName' type='text' required='required' placeholder='Required' name='FirstName' value='".(($_POST['FirstName'] <> "") ? htmlentities(stripslashes($_POST['FirstName']), ENT_QUOTES) : "")."' /></li> <li><label for='LastName' class='inline'>Last Name:</label> <input id='LastName' type='text' required='required' placeholder='Required' name='LastName' value='".(($_POST['LastName'] <> "") ? htmlentities(stripslashes($_POST['LastName']), ENT_QUOTES) : "")."' /></li> <li><label for='Company' class='inline'>Company:</label> <input id='Company' type='text' name='Company' value='".(($_POST['Company'] <> "") ? htmlentities(stripslashes($_POST['Company']), ENT_QUOTES) : "")."' /></li> <li><label for='Email' class='inline'>Email:</label> <input id='email' type='email' required='required' placeholder='Required' name='Email' value='".(($_POST['Email'] <> "") ? htmlentities(stripslashes($_POST['Email']), ENT_QUOTES) : "")."' /></li> <li><label for='Phone' class='inline'>Phone:</label> <input id='tel' type='tel' required='required' placeholder='Required' name='Phone' value='".(($_POST['Phone'] <> "") ? htmlentities(stripslashes($_POST['Phone']), ENT_QUOTES) : "")."' /></li> <li><label for='Address1' class='inline'>Address 1:</label> <input id='Address1' type='text' name='Address1' value='".(($_POST['Address1'] <> "") ? htmlentities(stripslashes($_POST['Address1']), ENT_QUOTES) : "")."' /></li> <li><label for='City' class='inline'>City:</label> <input id='City' type='text' name='City' value='".(($_POST['City'] <> "") ? htmlentities(stripslashes($_POST['City']), ENT_QUOTES) : "")."' /></li> <li><label for=\'State\'>State:</label><select name='State' size='1'><option value='' SELECTED>[State]</option><option value='ZZ'".(($_POST['State'] == 'ZZ') ? "selected" : "").">International</option><option value='AL'".(($_POST['State'] == 'AL') ? "selected" : "").">AL-Alabama</option><option value='AK'".(($_POST['State'] == 'AK') ? "selected" : "").">AK-Alaska</option><option value='AZ'".(($_POST['State'] == 'AZ') ? "selected" : "").">AZ-Arizona</option><option value='AR'".(($_POST['State'] == 'AR') ? "selected" : "").">AR-Arkansas</option><option value='CA'".(($_POST['State'] == 'CA') ? "selected" : "").">CA-California</option><option value='CO'".(($_POST['State'] == 'CO') ? "selected" : "").">CO-Colorado</option><option value='CT'".(($_POST['State'] == 'CT') ? "selected" : "").">CT-Connecticut</option><option value='DC'".(($_POST['State'] == 'DC') ? "selected" : "").">DC-Washington D.C.</option><option value='DE'".(($_POST['State'] == 'DE') ? "selected" : "").">DE-Delaware</option><option value='FL'".(($_POST['State'] == 'FL') ? "selected" : "").">FL-Florida</option><option value='GA'".(($_POST['State'] == 'GA') ? "selected" : "").">GA-Georgia</option><option value='HI'".(($_POST['State'] == 'HI') ? "selected" : "").">HI-Hawaii</option><option value='ID'".(($_POST['State'] == 'ID') ? "selected" : "").">ID-Idaho</option><option value='IL'".(($_POST['State'] == 'IL') ? "selected" : "").">IL-Illinois</option><option value='IN'".(($_POST['State'] == 'IN') ? "selected" : "").">IN-Indiana</option><option value='IA'".(($_POST['State'] == 'IA') ? "selected" : "").">IA-Iowa</option><option value='KS'".(($_POST['State'] == 'KS') ? "selected" : "").">KS-Kansas</option><option value='KY'".(($_POST['State'] == 'KY') ? "selected" : "").">KY-Kentucky</option><option value='LA'".(($_POST['State'] == 'LA') ? "selected" : "").">LA-Louisiana</option><option value='ME'".(($_POST['State'] == 'ME') ? "selected" : "").">ME-Maine</option><option value='MD'".(($_POST['State'] == 'MD') ? "selected" : "").">MD-Maryland</option><option value='MA'".(($_POST['State'] == 'MA') ? "selected" : "").">MA-Massachusetts</option><option value='MI'".(($_POST['State'] == 'MI') ? "selected" : "").">MI-Michigan</option><option value='MN'".(($_POST['State'] == 'MN') ? "selected" : "").">MN-Minnesota</option><option value='MS'".(($_POST['State'] == 'MS') ? "selected" : "").">MS-Mississippi</option><option value='MO'".(($_POST['State'] == 'MO') ? "selected" : "").">MO-Missouri</option><option value='MT'".(($_POST['State'] == 'MT') ? "selected" : "").">MT-Montana</option><option value='NE'".(($_POST['State'] == 'NE') ? "selected" : "").">NE-Nebraska</option><option value='NV'".(($_POST['State'] == 'NV') ? "selected" : "").">NV-Nevada</option><option value='NH'".(($_POST['State'] == 'NH') ? "selected" : "").">NH-New Hampshire</option><option value='NJ'".(($_POST['State'] == 'NJ') ? "selected" : "").">NJ-New Jersey</option><option value='NM'".(($_POST['State'] == 'NM') ? "selected" : "").">NM-New Mexico</option><option value='NY'".(($_POST['State'] == 'NY') ? "selected" : "").">NY-New York</option><option value='NC'".(($_POST['State'] == 'NC') ? "selected" : "").">NC-North Carolina</option><option value='ND'".(($_POST['State'] == 'ND') ? "selected" : "").">ND-North Dakota</option><option value='OH'".(($_POST['State'] == 'OH') ? "selected" : "").">OH-Ohio</option><option value='OK'".(($_POST['State'] == 'OK') ? "selected" : "").">OK-Oklahoma</option><option value='OR'".(($_POST['State'] == 'OR') ? "selected" : "").">OR-Oregon</option><option value='PA'".(($_POST['State'] == 'PA') ? "selected" : "").">PA-Pennsylvania</option><option value='PR'".(($_POST['State'] == 'PR') ? "selected" : "").">PR-Puerto Rico</option><option value='RI'".(($_POST['State'] == 'RI') ? "selected" : "").">RI-Rhode Island</option><option value='SC'".(($_POST['State'] == 'SC') ? "selected" : "").">SC-South Carolina</option><option value='SD'".(($_POST['State'] == 'SD') ? "selected" : "").">SD-South Dakota</option><option value='TN'".(($_POST['State'] == 'TN') ? "selected" : "").">TN-Tennessee</option><option value='TX'".(($_POST['State'] == 'TX') ? "selected" : "").">TX-Texas</option><option value='UT'".(($_POST['State'] == 'UT') ? "selected" : "").">UT-Utah</option><option value='VT'".(($_POST['State'] == 'VT') ? "selected" : "").">VT-Vermont</option><option value='VA'".(($_POST['State'] == 'VA') ? "selected" : "").">VA-Virginia</option><option value='WA'".(($_POST['State'] == 'WA') ? "selected" : "").">WA-Washington</option><option value='WV'".(($_POST['State'] == 'WV') ? "selected" : "").">WV-West Virginia</option><option value='WI'".(($_POST['State'] == 'WI') ? "selected" : "").">WI-Wisconsin</option><option value='WY'".(($_POST['State'] == 'WY') ? "selected" : "").">WY-Wyoming</option></select></li> <li><label for='Zip' class='inline'>Zip:</label> <input id='Zip' type='text' name='Zip' value='".(($_POST['Zip'] <> "") ? htmlentities(stripslashes($_POST['Zip']), ENT_QUOTES) : "")."' /></li> <li><td colspan=2><table width=100%><tr><td colspan=3>Please indicate the methods by which we may contact you:</td></tr><tr><td><input type='checkbox' class=clear name='ApprovedContactEmail' value='1' ".(($_POST['ApprovedContactEmail'] == "1") ? "CHECKED" : "CHECKED")." />email</td><td><input type='checkbox' class=clear name='ApprovedContactPhone' value='1' ".(($_POST['ApprovedContactPhone'] == "1") ? "CHECKED" : "CHECKED")." />phone</td><td><input type='checkbox' class=clear name='ApprovedContactPost' value='1' ".(($_POST['ApprovedContactPost'] == "1") ? "CHECKED" : "CHECKED")." />post</td></tr></table></li> "; $questionblock = "<li><label for='MAID:0000002581' class='oneline'>Job Title</label><input type='text' class='oneline' name='TEXT:0000002581' value='".(($_POST['TEXT:0000002581'] <> "") ? htmlentities(stripslashes($_POST['TEXT:0000002581']), ENT_QUOTES) : '')."' /></li> <li><label for='MAID:0000002579' class='oneline'>Web Site Address</label><input type='text' class='oneline' name='TEXT:0000002579' value='".(($_POST['TEXT:0000002579'] <> "") ? htmlentities(stripslashes($_POST['TEXT:0000002579']), ENT_QUOTES) : '')."' /></li> <li><label for='MAID:0000002576'>Please select your industry: (drop down from below)</label><select class='item' name='MAID:0000002576' size='1'><option value='0000042068' ".(($_POST['MAID:0000002576'] == '0000042068') ? "selected":"").">-select one-</option><option value='0000042069' ".(($_POST['MAID:0000002576'] == '0000042069') ? "selected":"").">Banking & Finance </option><option value='0000042080' ".(($_POST['MAID:0000002576'] == '0000042080') ? "selected":"").">Biotechnology & Pharmaceutical </option><option value='0000042074' ".(($_POST['MAID:0000002576'] == '0000042074') ? "selected":"").">Construction/Real Estate </option><option value='0000042070' ".(($_POST['MAID:0000002576'] == '0000042070') ? "selected":"").">Education</option><option value='0000042077' ".(($_POST['MAID:0000002576'] == '0000042077') ? "selected":"").">Government/Municipality/Union </option><option value='0000042071' ".(($_POST['MAID:0000002576'] == '0000042071') ? "selected":"").">Healthcare/Hospitals </option><option value='0000042072' ".(($_POST['MAID:0000002576'] == '0000042072') ? "selected":"").">Manufacturing </option><option value='0000042076' ".(($_POST['MAID:0000002576'] == '0000042076') ? "selected":"").">Non-Profit </option><option value='0000042073' ".(($_POST['MAID:0000002576'] == '0000042073') ? "selected":"").">Printing & Publishing </option><option value='0000042075' ".(($_POST['MAID:0000002576'] == '0000042075') ? "selected":"").">Professional Services</option><option value='0000042078' ".(($_POST['MAID:0000002576'] == '0000042078') ? "selected":"").">Technology </option><option value='0000042079' ".(($_POST['MAID:0000002576'] == '0000042079') ? "selected":"").">Transportation</option><option value='0000042230' ".(($_POST['MAID:0000002576'] == '0000042230') ? "selected":"").">Other</option></select></li> <li><label for='MAID:0000002577'>Company Size (by employees):</label><select class='item' name='MAID:0000002577' size='1'><option value='0000042081' ".(($_POST['MAID:0000002577'] == '0000042081') ? "selected":"").">-select one-</option><option value='0000042082' ".(($_POST['MAID:0000002577'] == '0000042082') ? "selected":"").">Under 500</option><option value='0000042083' ".(($_POST['MAID:0000002577'] == '0000042083') ? "selected":"").">500 - 1,000</option><option value='0000042084' ".(($_POST['MAID:0000002577'] == '0000042084') ? "selected":"").">1,001 - 5,000</option><option value='0000042085' ".(($_POST['MAID:0000002577'] == '0000042085') ? "selected":"").">5,001 - 10,000</option><option value='0000042095' ".(($_POST['MAID:0000002577'] == '0000042095') ? "selected":"").">10,000+</option></select></li> <li><label for='MAID:0000002578'>Timeframe to take control of your healthcare costs: </label><select class='item' name='MAID:0000002578' size='1'><option value='0000042086' ".(($_POST['MAID:0000002578'] == '0000042086') ? "selected":"").">-select one-</option><option value='0000042087' ".(($_POST['MAID:0000002578'] == '0000042087') ? "selected":"").">Today</option><option value='0000042088' ".(($_POST['MAID:0000002578'] == '0000042088') ? "selected":"").">1 month</option><option value='0000042089' ".(($_POST['MAID:0000002578'] == '0000042089') ? "selected":"").">3 months</option><option value='0000042090' ".(($_POST['MAID:0000002578'] == '0000042090') ? "selected":"").">6 months</option><option value='0000042091' ".(($_POST['MAID:0000002578'] == '0000042091') ? "selected":"").">1 year</option></select></li> "; $thanksTitle = 'WellNet Healthcare: Thank you for your inquiry'; $thanksHeader = 'Thank you for your interest.'; $thanksText = '<P>We follow up with you shortly. Meanwhile, please feel free to learn more about our <a href=http://www.wellnethealthcare.com/Healthcare-performance-products.html">products</a> and <a href=http://www.wellnethealthcare.com/Healthcare-management-services.html">services</a>.</p>';