Great, thank you for your response. Here is my PHP code.
<?php
$errors = array();
if ($_SERVER['REQUEST_METHOD']=="POST"){
$fields = array('information', 'requested_date_month', 'requested_date_day', 'requested_date_year', 'requested_time_hour', 'requested_time_minute', 'veterinarian', 'clinic_name', 'address', 'city', 'state', 'zip', 'email', 'client_name', 'animal_name', 'animal_age', 'animal_breed', 'animal_gender', 'animal_intact');
foreach ($fields as $field) {
if(!$_POST[$field]) {
array_push($errors, $field);
}
}
if((!$_POST['home_phone']) && (!$_POST['mobile_phone']) && (!$_POST['work_phone'])){ array_push($errors, 'phone'); }
if(count($errors) == 0){
// Assign TO, FROM, and SUBJECT
$to="eamil address here";
$from="CSU Animal Cancer Center <[email protected]";
$subject="CSU ACC rDVM Consulting Form Submission";
$diagnosis = stripslashes($_POST['diagnosis']);
$information = stripslashes($_POST['information']);
$requested_date_month = stripslashes($_POST['requested_date_month']);
$requested_date_day = stripslashes($_POST['requested_date_day']);
$requested_date_year = stripslashes($_POST['requested_date_year']);
$requested_time_hour = stripslashes($_POST['requested_time_hour']);
$requested_time_minute = stripslashes($_POST['requested_time_minute']);
$time_am_pm = stripslashes($_POST['time_am_pm']);
$veterinarian = stripslashes($_POST['veterinarian']);
$clinic_name = stripslashes($_POST['clinic_name']);
$address = stripslashes($_POST['address']);
$city = stripslashes($_POST['city']);
$state = stripslashes($_POST['state']);
$zip = stripslashes($_POST['zip']);
$home_phone = stripslashes($_POST['home_phone']);
$work_phone = stripslashes($_POST['work_phone']);
$mobile_phone = stripslashes($_POST['mobile_phone']);
$fax = stripslashes($_POST['fax']);
$email = stripslashes($_POST['email']);
$not_avail_from_time_hour = stripslashes($_POST['not_avail_from_time_hour']);
$not_avail_from_time_minute = stripslashes($_POST['not_avail_from_time_minute']);
$not_avail_from_ampm = stripslashes($_POST['not_avail_from_ampm']);
$not_avail_to_time_hour = stripslashes($_POST['not_avail_to_time_hour']);
$not_avail_to_time_minute = stripslashes($_POST['not_avail_to_time_minute']);
$not_avail_to_ampm = stripslashes($_POST['not_avail_to_ampm']);
$client_name = stripslashes($_POST['client_name']);
$animal_name = stripslashes($_POST['animal_name']);
$animal_age = stripslashes($_POST['animal_age']);
$animal_breed = stripslashes($_POST['animal_breed']);
$animal_gender = stripslashes($_POST['animal_gender']);
$animal_intact = stripslashes($_POST['animal_intact']);
// Message is built here
$message = "<div style='font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 12px;'>
<img src='http://www.csuanimalcancercenter.org/assets/images/ACC_consult_hdr_v2.jpg' width='575' height='101' alt='Colorado State University Animal Cancer Center - Advancing Cancer Center' />
<h4 style='text-decoration: underline; font-size: 18px;'>rDVM Consulting Form</h4>
<p><strong>Assigned to:</strong> _______________________________________ <strong>Consult #:</strong> ____________</p>
<p style='width: 575px;'><strong>Diagnosis:</strong> $diagnosis</p>
<p style='width: 575px;'><strong>What information can we help you with?</strong> $information</p>
<p><strong>Requested Date:</strong> $requested_date_month $requested_date_day, $requested_date_year <strong>Time:</strong> $requested_time_hour:$requested_time_minute $time_am_pm</p>
<p><strong>Issued Date:</strong> __________________ <strong>Time:</strong> _________________ AM/PM</p>
<p><strong>Veterinarian:</strong> $veterinarian // <strong>Clinic name:</strong> $clinic_name</p>
<p><strong>Address:</strong> $address, $city, $state $zip</p>
<table cellpadding='0' cellspacing='0' style='font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 12px;'>
<tr>
<td colspan='5'><strong>Phone:</strong></td>
</tr>
<tr>
<td width='20'></td>
<td><em>(home)</em> </td>
<td>$home_phone</td>
<td> <em>(work)</em> </td>
<td>$work_phone</td>
</tr>
<tr>
<td width='20'></td>
<td><em>(mobile)</em> </td>
<td>$mobile_phone</td>
<td> <em>(fax)</em> </td>
<td>$fax</td>
</tr>
</table>
<p><strong>Email:</strong> <a href='mailto:$email'>$email</a></p>
<p>Time(s) <strong><em><u>NOT</u></em></strong> available: Time: $not_avail_to_time_hour:$not_avail_to_time_minute $not_avail_to_ampm from Time: $not_avail_from_time_hour:$not_avail_from_time_minute $not_avail_from_ampm</p>
<p><strong>Client's name:</strong> $client_name</p>
<p><strong>Animal's name:</strong> $animal_name // <strong>Age:</strong> $animal_age // <strong>Breed:</strong> $animal_breed</p>
<p><strong>Sex:</strong> $animal_gender // <strong>Status:</strong> $animal_intact</p>
<p><strong><em>Office use only:</em></strong></p>
<img src='http://www.csuanimalcancercenter.org/assets/images/ACC_box_v1.jpg' width='575' height='226' />
<p>Faxes to be sent: _______________ Return Date: ___________ Time: ___________ AM/PM</p>
<p>Messages Left: ____________________________________________________________</p>
<p><strong>Please return to:</strong> <em>(email)</em> <a href='mailto:mail here'>email here</a>, or <em>(fax)</em> (970) 297-1254</p>
<img src='http://www.csuanimalcancercenter.org/assets/images/ACC_consult_ftr_v2.jpg' width='575' height='32' alt='Copyright 2010 Animal Cancer Center - Colorado State University, 300 West Drake Road, Fort Collins, CO 80523 USA' />
</div>";
// End build message
$headers = "MIME-Version: 1.0\r\n";
$headers.= "Content-type: text/html; charset=iso-8859-1\r\n";
$headers.= "From: [email protected]\r\n";
if (mail($to, $subject, $message, $headers)) {
header('Location: http://www.csuanimalcancercenter.org/consult-submission');
}
else {
echo "<p>The form submission has failed.</p>";
}
}
} if($_SERVER['REQUEST_METHOD']!="POST" || count($errors) > 0){
?>
<div style="margin: 0px 10px; width: 500px;">
<?php if(count($errors) > 0){ echo '<p style="color: red; text-align: center;">There are problems with your form submission. See below for missing fields.</p>'; } ?>
<form action="<?php echo $_SERVER['PHP_SELF']; ?>" method="post" name="rdvm_consulting">
<p>Diagnosis:<br />
<textarea name="diagnosis" rows="3" cols="75"><?php echo $_POST['diagnosis']; ?></textarea>
</p>
<p><font color="red">*</font> What information can we help you with?:<br /><textarea name="information" rows="8" cols="75"><?php echo $_POST['information']; ?></textarea>
<?php if(in_array('information', $errors)){ echo '<br /><span style="color: red;">Required Field</span>'; } ?></p>
<p><font color="red">*</font> Requested Date:
<select name="requested_date_month">
<?php
$months = array('', 'January', 'February', 'March', 'April', 'May', 'June', 'July', 'August', 'September', 'October', 'November', 'December');
foreach ($months as $month) {
$echo_month = '<option value="' . $month . '"';
if($_POST['requested_date_month'] == $month){ $echo_month .= ' selected'; }
$echo_month .= '>' . $month . '</option>';
echo $echo_month;
}
?>
</select>
<select name="requested_date_day">
<option value=''></option>
<?php
$days = range(1,31);
foreach ($days as $day) {
$echo_day = '<option value="' . $day . '"';
if($_POST['requested_date_day'] == $day){ $echo_day .= ' selected'; }
$echo_day .= '>' . $day . '</option>';
echo $echo_day;
}
?>
</select>
<select name="requested_date_year">
<option value=''></option>
<?php
$this_year = date('Y');
$num_years = 11;
$i = 0;
while ($i < $num_years) {
$year = $this_year + $i;
$echo_year = '<option value="' . $year . '"';
if($_POST['requested_date_year'] == $year){ $echo_year .= ' selected'; }
$echo_year .= '>' . $year . '</option>';
echo $echo_year;
$i++;
}
?>
</select>
<font color="red">*</font> Time:
<select name="requested_time_hour">
<option value=''></option>
<?php
$hours = range(1,12);
foreach ($hours as $hour) {
$echo_hour = '<option value="' . $hour . '"';
if($_POST['requested_time_hour'] == $hour){ $echo_hour .= ' selected'; }
$echo_hour .= '>' . $hour . '</option>';
echo $echo_hour;
}
?>
</select>:<select name="requested_time_minute">
<option value=''></option>
<option value='00' <?php if($_POST['requested_time_minute'] == '00'){ echo 'selected'; } ?>>00</option>
<option value='01' <?php if($_POST['requested_time_minute'] == '01'){ echo 'selected'; } ?>>01</option>
<option value='02' <?php if($_POST['requested_time_minute'] == '02'){ echo 'selected'; } ?>>02</option>
<option value='03' <?php if($_POST['requested_time_minute'] == '03'){ echo 'selected'; } ?>>03</option>
<option value='04' <?php if($_POST['requested_time_minute'] == '04'){ echo 'selected'; } ?>>04</option>
<option value='05' <?php if($_POST['requested_time_minute'] == '05'){ echo 'selected'; } ?>>05</option>
<option value='06' <?php if($_POST['requested_time_minute'] == '06'){ echo 'selected'; } ?>>06</option>
<option value='07' <?php if($_POST['requested_time_minute'] == '07'){ echo 'selected'; } ?>>07</option>
<option value='08' <?php if($_POST['requested_time_minute'] == '08'){ echo 'selected'; } ?>>08</option>
<option value='09' <?php if($_POST['requested_time_minute'] == '09'){ echo 'selected'; } ?>>09</option>
<?php
$minutes = range(10,59);
foreach ($minutes as $minute) {
$echo_minute = '<option value="' . $minute . '"';
if($_POST['requested_time_minute'] == $minute){ $echo_minute .= ' selected'; }
$echo_minute .= '>' . $minute . '</option>';
echo $echo_minute;
}
?>
</select>
<select name="time_am_pm">
<?php
$am_pm = array('AM', 'PM');
foreach ($am_pm as $apm) {
$echo_am_pm = '<option value="' . $apm . '"';
if($_POST['time_am_pm'] == $apm){ $echo_am_pm .= ' selected'; }
$echo_am_pm .= '>' . $apm . '</option>';
echo $echo_am_pm;
}
?>
</select>
<?php if(in_array('requested_date_day', $errors) || in_array('requested_date_month', $errors) || in_array('requested_date_year', $errors) || in_array('requested_time_hour', $errors) || in_array('requested_time_minute', $errors)){ echo ' <span style="color: red;">Required Field</span>'; } ?>
</p>
<table width="600" height="35" border="0" cellpadding="0" cellspacing="0">
<tr>
<td><font color="red">*</font> Veterinarian:
<input type="text" name="veterinarian" size="27" value="<?php echo $_POST['veterinarian']; ?>"> <font color="red">*</font> Clinic name:
<input type="text" name="clinic_name" size="27" value="<?php echo $_POST['clinic_name']; ?>">
<?php if((in_array('clinic_name', $errors)) || (in_array('clinic_name', $errors))){ echo ' <span style="color: red;">Required Field</span>'; } ?></td>
</tr>
</table>
<p><font color="red">*</font> Address:
<input type="text" name="address" size="20" value="<?php echo $_POST['address']; ?>">
<font color="red">*</font> City:
<input type="text" name="city" size="15" value="<?php echo $_POST['city']; ?>"></p>
<p> <font color="red">*</font> State:
<select name="state">
<?php
$states = array('', 'Alabama', 'Alaska', 'Arizona', 'Arkansas', 'California', 'Colorado', 'Connecticut', 'Delaware', 'Florida', 'Georgia', 'Hawaii', 'Idaho', 'Illinois', 'Indiana', 'Iowa', 'Kansas', 'Kentucky', 'Louisiana', 'Maine', 'Maryland', 'Massachusetts', 'Michigan', 'Minnesota', 'Mississippi', 'Missouri', 'Montana', 'Nebraska', 'Nevada', 'New Hampshire', 'New Jersey', 'New Mexico', 'New York', 'North Carolina', 'North Dakota', 'Ohio', 'Oklahoma', 'Oregon', 'Pennsylvania', 'Rhode Island', 'South Carolina', 'South Dakota', 'Tennessee', 'Texas', 'Utah', 'Vermont', 'Virginia', 'Washington', 'West Virginia', 'Wisconsin', 'Wyoming');
foreach ($states as $state) {
$echo_state = '<option value="' . $state . '"';
if($_POST['state'] == $state){ $echo_state .= ' selected'; }
$echo_state .= '>' . $state . '</option>';
echo $echo_state;
}
?>
</select>
<font color="red">*</font> Zip:
<input type="text" name="zip" size="5" value="<?php echo $_POST['zip']; ?>">
<?php if((in_array('address', $errors)) || (in_array('city', $errors)) || (in_array('state', $errors)) || (in_array('zip', $errors))){ echo ' <span style="color: red;">Required Field</span>'; } ?>
</p>
<table cellpadding="0" cellspacing="0">
<tr>
<td colspan="5"><font color="red">*</font> Phone:</td>
</tr>
<tr>
<td width="20"> </td>
<td style="font-size: 80%;" align="right"><em>(home)</em> </td>
<td><input type="text" name="home_phone" size="25" value="<?php echo $_POST['home_phone']; ?>"></td>
<td style="font-size: 80%;" align="right"> <em>(work)</em> </td>
<td><input type="text" name="work_phone" size="25" value="<?php echo $_POST['work_phone']; ?>"></td>
</tr>
<tr>
<td width="20"></td>
<td style="font-size: 80%;" align="right"><em>(mobile)</em> </td>
<td><input type="text" name="mobile_phone" size="25" value="<?php echo $_POST['mobile_phone']; ?>"></td>
<td style="font-size: 80%;" align="right"> <em>(fax)</em> </td>
<td><input type="text" name="fax" size="25" value="<?php echo $_POST['fax']; ?>"></td>
</tr>
<tr>
<td width="20"></td>
<td colspan="4"><?php if(in_array('phone', $errors)){ echo ' <span style="color: red;">At Least One Phone Number is Required</span>'; } ?></td>
</tr>
</table>
<p><font color="red">*</font> Email:
<input type="text" name="email" size="65" value="<?php echo $_POST['email']; ?>"><?php if(in_array('email', $errors)){ echo ' <span style="color: red;">Required Field</span>'; } ?></p>
</br>
<p>Time(s) <strong><em><u>NOT</u></em></strong> available: Time:
<select name="not_avail_to_time_hour">
<option value=''></option>
<?php
$thours = range(1,12);
foreach ($thours as $thour) {
$echo_thour = '<option value="' . $thour . '"';
if($_POST['not_avail_to_time_hour'] == $thour){ $echo_thour .= ' selected'; }
$echo_thour .= '>' . $thour . '</option>';
echo $echo_thour;
}
?>
</select>
:
<select name="not_avail_to_time_minute">
<option value=''></option>
<option value='00' <?php if($_POST['not_avail_to_time_minute'] == '00'){ echo 'selected'; } ?>>00</option>
<option value='01' <?php if($_POST['not_avail_to_time_minute'] == '01'){ echo 'selected'; } ?>>01</option>
<option value='02' <?php if($_POST['not_avail_to_time_minute'] == '02'){ echo 'selected'; } ?>>02</option>
<option value='03' <?php if($_POST['not_avail_to_time_minute'] == '03'){ echo 'selected'; } ?>>03</option>
<option value='04' <?php if($_POST['not_avail_to_time_minute'] == '04'){ echo 'selected'; } ?>>04</option>
<option value='05' <?php if($_POST['not_avail_to_time_minute'] == '05'){ echo 'selected'; } ?>>05</option>
<option value='06' <?php if($_POST['not_avail_to_time_minute'] == '06'){ echo 'selected'; } ?>>06</option>
<option value='07' <?php if($_POST['not_avail_to_time_minute'] == '07'){ echo 'selected'; } ?>>07</option>
<option value='08' <?php if($_POST['not_avail_to_time_minute'] == '08'){ echo 'selected'; } ?>>08</option>
<option value='09' <?php if($_POST['not_avail_to_time_minute'] == '09'){ echo 'selected'; } ?>>09</option>
<?php
$tminutes = range(10,59);
foreach ($tminutes as $tminute) {
$echo_tminute = '<option value="' . $tminute . '"';
if($_POST['not_avail_to_time_minute'] == $tminute){ $echo_tminute .= ' selected'; }
$echo_tminute .= '>' . $tminute . '</option>';
echo $echo_tminute;
}
?>
</select>
<select name="not_avail_to_ampm">
<?php
$to_am_pm = array('AM', 'PM');
foreach ($to_am_pm as $tapm) {
$echo_to_am_pm = '<option value="' . $tapm . '"';
if($_POST['not_avail_to_ampm'] == $apm){ $echo_to_am_pm .= ' selected'; }
$echo_to_am_pm .= '>' . $tapm . '</option>';
echo $echo_to_am_pm;
}
?>
</select>
from
<select name="not_avail_from_time_hour">
<option value=''></option>
<?php
$fhours = range(1,12);
foreach ($fhours as $fhour) {
$echo_fhour = '<option value="' . $fhour . '"';
if($_POST['not_avail_from_time_hour'] == $fhour){ $echo_fhour .= ' selected'; }
$echo_fhour .= '>' . $fhour . '</option>';
echo $echo_fhour;
}
?>
</select>
:
<select name="not_avail_from_time_minute">
<option value=''></option>
<option value='00' <?php if($_POST['not_avail_from_time_minute'] == '00'){ echo 'selected'; } ?>>00</option>
<option value='01' <?php if($_POST['not_avail_from_time_minute'] == '01'){ echo 'selected'; } ?>>01</option>
<option value='02' <?php if($_POST['not_avail_from_time_minute'] == '02'){ echo 'selected'; } ?>>02</option>
<option value='03' <?php if($_POST['not_avail_from_time_minute'] == '03'){ echo 'selected'; } ?>>03</option>
<option value='04' <?php if($_POST['not_avail_from_time_minute'] == '04'){ echo 'selected'; } ?>>04</option>
<option value='05' <?php if($_POST['not_avail_from_time_minute'] == '05'){ echo 'selected'; } ?>>05</option>
<option value='06' <?php if($_POST['not_avail_from_time_minute'] == '06'){ echo 'selected'; } ?>>06</option>
<option value='07' <?php if($_POST['not_avail_from_time_minute'] == '07'){ echo 'selected'; } ?>>07</option>
<option value='08' <?php if($_POST['not_avail_from_time_minute'] == '08'){ echo 'selected'; } ?>>08</option>
<option value='09' <?php if($_POST['not_avail_from_time_minute'] == '09'){ echo 'selected'; } ?>>09</option>
<?php
$fminutes = range(10,59);
foreach ($fminutes as $fminute) {
$echo_fminute = '<option value="' . $fminute . '"';
if($_POST['not_avail_from_time_minute'] == $fminute){ $echo_fminute .= ' selected'; }
$echo_fminute .= '>' . $fminute . '</option>';
echo $echo_fminute;
}
?>
</select>
<select name="not_avail_from_ampm">
<?php
$from_am_pm = array('AM', 'PM');
foreach ($from_am_pm as $fapm) {
$echo_from_am_pm = '<option value="' . $fapm . '"';
if($_POST['not_avail_from_ampm'] == $fapm){ $echo_from_am_pm .= ' selected'; }
$echo_from_am_pm .= '>' . $fapm . '</option>';
echo $echo_from_am_pm;
}
?>
</select>
</p>
<p><font color="red">*</font> Client's Name:
<input type="text" name="client_name" size="60" value="<?php echo $_POST['client_name']; ?>"><?php if(in_array('client_name', $errors)){ echo ' <span style="color: red;">Required Field</span>'; } ?></p>
<p><font color="red">*</font> Animal's name:
<input type="text" name="animal_name" size="25" value="<?php echo $_POST['animal_name']; ?>">
<font color="red">*</font> Age:
<input type="text" name="animal_age" size="3" value="<?php echo $_POST['animal_age']; ?>"> </p>
<p><font color="red">*</font> Breed:
<input type="text" name="animal_breed" size="25" value="<?php echo $_POST['animal_breed']; ?>">
<?php if((in_array('animal_name', $errors)) || (in_array('animal_age', $errors)) || (in_array('animal_breed', $errors))){ echo ' <span style="color: red;">Required Field</span>'; } ?>
</p>
<p>
<font color="red">*</font> Sex:
<select name="animal_gender">
<?php
$an_gender = array('', 'Male', 'Female');
foreach ($an_gender as $gen) {
$echo_gen = '<option value="' . $gen . '"';
if($_POST['animal_gender'] == $gen){ $echo_gen .= ' selected'; }
$echo_gen .= '>' . $gen . '</option>';
echo $echo_gen;
}
?>
</select>
<font color="red">*</font> Status:
<select name="animal_intact">
<?php
$an_intact = array('', 'Castrated', 'Spayed', 'Intact');
foreach ($an_intact as $int) {
$echo_int = '<option value="' . $int . '"';
if($_POST['animal_intact'] == $int){ $echo_int .= ' selected'; }
$echo_int .= '>' . $int . '</option>';
echo $echo_int;
}
?>
</select>
<?php if((in_array('animal_gender', $errors)) || (in_array('animal_intact', $errors))){ echo ' <span style="color: red;">Required Field</span>'; } ?>
</p>
<p> </p>
<p><input type="submit" name="Submit" value="Submit"></p>
<p class="bodytext"><font color="red">*<em> Denotes Required Field</em></font></p>
</form>
</div>
<?php } ?>
</div>