Formtest

</p> <p><?</p> <p>if($_POST[‘sent’] == 1)<br /> {</p> <p>//foreach ($_POST as $value) {<br /> // if($value == “”){ $error = “<span style="color: #ff0000;">Alle velden dienen ingevuld te worden.</span>“; }<br /> //}</p> <p>while(list($key,$value)=each($_POST)) {<br /> if($key != “opmerkingen” && $key != “Telefoonnummer2”){</p> <p>if($value == “”){ $error = “<span style="color: #ff0000;">Alle velden dienen ingevuld te worden.</span>“; }<br /> }<br /> }</p> <p>if($error == “”)<br /> {</p> <p>$formulier = ‘<br /> AANMELDFORMULIER</p> <table border="1" width="100%" cellpadding="4"> <tbody> <tr> <td colspan="2" align="left" valign="top"><b>Personalia</b></td> </tr> <tr> <td align="left" valign="top" width="50%">Voorletters</td> <td align="left" valign="top" width="50%">‘.$_POST[‘Voorletters’].’</td> </tr> <tr> <td align="left" valign="top">Meisjes achternaam</td> <td align="left" valign="top">‘.$_POST[‘Meisjesachternaam’].’</td> </tr> <tr> <td align="left" valign="top">Roepnaam</td> <td align="left" valign="top">‘.$_POST[‘Roepnaam’].’</td> </tr> <tr> <td align="left" valign="top">Geboortedatum</td> <td align="left" valign="top">‘.$_POST[‘Geboortedatum’].’</td> </tr> <tr> <td align="left" valign="top">Geboorteland</td> <td align="left" valign="top">‘.$_POST[‘Geboorteland’].’</td> </tr> <tr> <td align="left" valign="top">Burger service nummer (SOFI) 2</td> <td align="left" valign="top">‘.$_POST[‘bsn’].’</td> </tr> <tr> <td align="left" valign="top">Naam verzekeringsmaatschappij</td> <td align="left" valign="top">‘.$_POST[‘verzekeringsmaatschappij’].’</td> </tr> <tr> <td align="left" valign="top">Polisnummer</td> <td align="left" valign="top">‘.$_POST[‘Polisnummer’].’</td> </tr> <tr> <td align="left" valign="top">Verzekering</td> <td align="left" valign="top">‘.$_POST[‘Verzekering’].’</td> </tr> <tr> <td align="left" valign="top">Burgerlijke staat</td> <td align="left" valign="top">‘.$_POST[‘Burgerlijkestaat’].’</td> </tr> <tr> <td align="left" valign="top">indien gehuwd, gebruik meisjesnaam</td> <td align="left" valign="top">‘.$_POST[‘meisjesnaam_gebruik’].’</td> </tr> <tr> <td align="left" valign="top">Religie</td> <td align="left" valign="top">‘.$_POST[‘Religie’].’</td> </tr> <tr> <td align="left" valign="top">Spreektaal</td> <td align="left" valign="top">‘.$_POST[‘Spreektaal’].’</td> </tr> <tr> <td colspan="2" align="left" valign="top"></td> </tr> <tr> <td colspan="2" align="left" valign="top"><b>Personalia partner</b></td> </tr> <tr> <td align="left" valign="top">Voorletters</td> <td align="left" valign="top">‘.$_POST[‘Voorletters_partner’].’</td> </tr> <tr> <td align="left" valign="top">Achternaam</td> <td align="left" valign="top">‘.$_POST[‘Achternaam_partner’].’</td> </tr> <tr> <td align="left" valign="top">Roepnaam</td> <td align="left" valign="top">‘.$_POST[‘Roepnaam_partner’].’</td> </tr> <tr> <td align="left" valign="top">Geboortedatum</td> <td align="left" valign="top">‘.$_POST[‘Geboortedatum_partner’].’</td> </tr> <tr> <td align="left" valign="top">Geboorteland</td> <td align="left" valign="top">‘.$_POST[‘Geboorteland_partner’].’</td> </tr> <tr> <td align="left" valign="top">Religie</td> <td align="left" valign="top">‘.$_POST[‘Religie_partner’].’</td> </tr> <tr> <td align="left" valign="top">Spreektaal</td> <td align="left" valign="top">‘.$_POST[‘Spreektaal_partner’].’</td> </tr> <tr> <td colspan="2" align="left" valign="top"></td> </tr> <tr> <td align="left" valign="top">Straatnaam</td> <td align="left" valign="top">‘.$_POST[‘Straatnaam’].’</td> </tr> <tr> <td align="left" valign="top">Huisnummer</td> <td align="left" valign="top">‘.$_POST[‘Huisnummer’].’</td> </tr> <tr> <td align="left" valign="top">Postcode</td> <td align="left" valign="top">‘.$_POST[‘Postcode’].’</td> </tr> <tr> <td align="left" valign="top">Woonplaats</td> <td align="left" valign="top">‘.$_POST[‘Woonplaats’].’</td> </tr> <tr> <td align="left" valign="top">Telefoonnummer 1</td> <td align="left" valign="top">‘.$_POST[‘Telefoonnummer1′].’</td> </tr> <tr> <td align="left" valign="top">Telefoonnummer 2</td> <td align="left" valign="top">‘.$_POST[‘Telefoonnummer2′].’</td> </tr> <tr> <td align="left" valign="top">Email</td> <td align="left" valign="top">‘.$_POST[‘Emailadres’].’</td> </tr> <tr> <td align="left" valign="top">Naam huisarts</td> <td align="left" valign="top">‘.$_POST[‘huisarts’].’</td> </tr> <tr> <td align="left" valign="top">Apotheek</td> <td align="left" valign="top">‘.$_POST[‘Apotheek’].’</td> </tr> <tr> <td align="left" valign="top">Datum eerste dag laatste menstruatie (dd-mm-jjjj)</td> <td align="left" valign="top">‘.$_POST[‘Menstruatie’].’</td> </tr> <tr> <td align="left" valign="top">Is deze datum zeker?</td> <td align="left" valign="top">‘.$_POST[‘menstruatie_zeker’].’</td> </tr> <tr> <td align="left" valign="top">Hoeveelste zwangerschap is dit voor je?</td> <td align="left" valign="top">‘.$_POST[‘zwangerschap’].’</td> </tr> <tr> <td align="left" valign="top">Hoeveel kinderen heb je?</td> <td align="left" valign="top">‘.$_POST[‘kinderen’].’</td> </tr> <tr> <td align="left" valign="top">Heb je ooit een miskraam gehad?</td> <td align="left" valign="top">‘.$_POST[‘miskraam’].’</td> </tr> <tr> <td align="left" valign="top">Gewicht</td> <td align="left" valign="top">‘.$_POST[‘gewicht’].’ kg</td> </tr> <tr> <td align="left" valign="top">Overige opmerkingen</td> <td align="left" valign="top">‘.$_POST[‘opmerkingen’].’</td> </tr> </tbody> </table> <p>‘;</p> <p>// To send the HTML mail we need to set the Content-type header.<br /> $headers = “MIME-Version: 1.0\r\n”;<br /> $headers .= “Content-type: text/html; charset=iso-8859-1\r\n”;<br /> $headers .= “From: website@verloskundigenwageningen.nl\r\n”;<br /> //options to send to cc+bcc<br /> //$headers .= “Cc: [email]maa@p-i-s.cXom[/email]”;<br /> //$headers .= “Bcc: [email]email@maaking.cXom[/email]”;</p> <p>// now lets send the email.<br /> mail(“verloskundigen.wageningen@gmail.com”, “aanmeldformulier: “.$_POST[‘Roepnaam’].” “.$_POST[‘Meisjesachternaam’] , $formulier, $headers);<br /> //mail(“info@qood.nl”, “aanmeldformulier: “.$_POST[‘Roepnaam’].” “.$_POST[‘Meisjesachternaam’] , $formulier, $headers);<br /> //mail(“info@qood.nl”, “aanmeldformulier: “.$_POST[‘Roepnaam’].” “.$_POST[‘Meisjesachternaam’] , $formulier, $headers);</p> <p>echo “Thank you for filling in this application form. We will contact you as soon as possible.”;</p> <p>}</p> <p>}</p> <p>if($_POST[‘sent’] != 1 || $error != “”){</p> <p>if($error != “”)<br /> {<br /> echo $error.”</p> <p>“;<br /> }<br /> ?></p> <p><span class="header">Application form</span></p> <p>After completion of this form we will contact you within three working days to make a first appointment. Please check the form carefully before sending it. Thank you very much.</p> <form action="?page=aanmeldformulier_engels" method="post" name="application form"> <table width="100%"> <tbody> <tr> <td colspan="2" align="left" valign="top"><b>Woman´s personal details</b></td> </tr> <tr> <td align="left" valign="top" width="300">Initials</td> <td align="left" valign="top"><input class="inputtekst" name="Voorletters" type="text" value="<?=$_POST['Voorletters'];?>" /></td> </tr> <tr> <td align="left" valign="top">Maiden name</td> <td align="left" valign="top"><input class="inputtekst" name="Meisjesachternaam" type="text" value="<?=$_POST['Meisjesachternaam'];?>" /></td> </tr> <tr> <td align="left" valign="top">First name</td> <td align="left" valign="top"><input class="inputtekst" name="Roepnaam" type="text" value="<?=$_POST['Roepnaam'];?>" /></td> </tr> <tr> <td align="left" valign="top">Date of birth</td> <td align="left" valign="top"><input class="inputtekst" name="Geboortedatum" type="text" value="<?=$_POST['Geboortedatum'];?>" /></td> </tr> <tr> <td align="left" valign="top">Place of birth</td> <td align="left" valign="top"><input class="inputtekst" name="Geboorteland" type="text" value="<?=$_POST['Geboorteland'];?>" /></td> </tr> <tr> <td align="left" valign="top">Tax and social security number (BSN/SOFI)</td> <td align="left" valign="top"><input class="inputtekst" name="bsn" type="text" value="<?=$_POST['bsn'];?>" /></td> </tr> <tr> <td align="left" valign="top">Health Insurance company</td> <td align="left" valign="top"><input class="inputtekst" name="verzekeringsmaatschappij" type="text" value="<?=$_POST['verzekeringsmaatschappij'];?>" /></td> </tr> <tr> <td align="left" valign="top">Policy number</td> <td align="left" valign="top"><input class="inputtekst" name="Polisnummer" type="text" value="<?=$_POST['Polisnummer'];?>" /></td> </tr> <tr> <td align="left" valign="top">Insurance:</td> <td align="left" valign="top"><input checked="checked" name="Verzekering" type="radio" value="Basic" />/> Basic<br /> <input checked="checked" name="Verzekering" type="radio" value="Complementary" />/> Complementary</td> </tr> <tr> <td align="left" valign="top">Marital status:</td> <td align="left" valign="top"><input checked="checked" name="Burgerlijkestaat" type="radio" value="Gehuwd" />/> Married<br /> <input checked="checked" name="Burgerlijkestaat" type="radio" value="Samenwonend" />/> Living together<br /> <input checked="checked" name="Burgerlijkestaat" type="radio" value="Alleenstaand" />/> Single</td> </tr> <tr> <td align="left" valign="top">If married, use maiden name</td> <td align="left" valign="top"><select name="meisjesnaam_gebruik"><option selected="selected" value="ja">>yes</option><option selected="selected" value="nee">>no</option></select></td> </tr> <tr> <td align="left" valign="top">Religion</td> <td align="left" valign="top"><input class="inputtekst" name="Religie" type="text" value="<?=$_POST['Religie'];?>" /></td> </tr> <tr> <td align="left" valign="top">Spoken language</td> <td align="left" valign="top"><input class="inputtekst" name="Spreektaal" type="text" value="<?=$_POST['Spreektaal'];?>" /></td> </tr> <tr> <td colspan="2" align="left" valign="top"></td> </tr> <tr> <td colspan="2" align="left" valign="top"><b>Partner´s personal details</b></td> </tr> <tr> <td align="left" valign="top">Initials</td> <td align="left" valign="top"><input class="inputtekst" name="Voorletters_partner" type="text" value="<?=$_POST['Voorletters_partner'];?>" /></td> </tr> <tr> <td align="left" valign="top">Surname</td> <td align="left" valign="top"><input class="inputtekst" name="Achternaam_partner" type="text" value="<?=$_POST['Achternaam_partner'];?>" /></td> </tr> <tr> <td align="left" valign="top">First name</td> <td align="left" valign="top"><input class="inputtekst" name="Roepnaam_partner" type="text" value="<?=$_POST['Roepnaam_partner'];?>" /></td> </tr> <tr> <td align="left" valign="top">Date of Birth</td> <td align="left" valign="top"><input class="inputtekst" name="Geboortedatum_partner" type="text" value="<?=$_POST['Geboortedatum_partner'];?>" /></td> </tr> <tr> <td align="left" valign="top">Place of Birth</td> <td align="left" valign="top"><input class="inputtekst" name="Geboorteland_partner" type="text" value="<?=$_POST['Geboorteland_partner'];?>" /></td> </tr> <tr> <td align="left" valign="top">Religion</td> <td align="left" valign="top"><input class="inputtekst" name="Religie_partner" type="text" value="<?=$_POST['Religie_partner'];?>" /></td> </tr> <tr> <td align="left" valign="top">Spoken language</td> <td align="left" valign="top"><input class="inputtekst" name="Spreektaal_partner" type="text" value="<?=$_POST['Spreektaal_partner'];?>" /></td> </tr> <tr> <td colspan="2" align="left" valign="top"></td> </tr> <tr> <td align="left" valign="top">Street name</td> <td align="left" valign="top"><input class="inputtekst" name="Straatnaam" type="text" value="<?=$_POST['Straatnaam'];?>" /></td> </tr> <tr> <td align="left" valign="top">House number</td> <td align="left" valign="top"><input class="inputtekst" name="Huisnummer" type="text" value="<?=$_POST['Huisnummer'];?>" /></td> </tr> <tr> <td align="left" valign="top">Postal code</td> <td align="left" valign="top"><input class="inputtekst" name="Postcode" type="text" value="<?=$_POST['Postcode'];?>" /></td> </tr> <tr> <td align="left" valign="top">Town</td> <td align="left" valign="top"><input class="inputtekst" name="Woonplaats" type="text" value="<?=$_POST['Woonplaats'];?>" /></td> </tr> <tr> <td align="left" valign="top">Telephone number 1</td> <td align="left" valign="top"><input class="inputtekst" name="Telefoonnummer1" type="text" value="<?=$_POST['Telefoonnummer1'];?>" /></td> </tr> <tr> <td align="left" valign="top">Telephone number 2</td> <td align="left" valign="top"><input class="inputtekst" name="Telefoonnummer2" type="text" value="<?=$_POST['Telefoonnummer2'];?>" /></td> </tr> <tr> <td align="left" valign="top">Email</td> <td align="left" valign="top"><input class="inputtekst" name="Emailadres" type="text" value="<?=$_POST['Emailadres'];?>" /></td> </tr> <tr> <td align="left" valign="top">Family Doctor</td> <td align="left" valign="top"><input class="inputtekst" name="huisarts" type="text" value="<?=$_POST['huisarts'];?>" /></td> </tr> <tr> <td align="left" valign="top">Pharmacy (name or street name)</td> <td align="left" valign="top"><input class="inputtekst" name="Apotheek" type="text" value="<?=$_POST['Apotheek'];?>" /></td> </tr> <tr> <td align="left" valign="top">Date first day of last menstrual period (dd-mm-yyyy)</td> <td align="left" valign="top"><input class="inputtekst" name="Menstruatie" type="text" value="<?=$_POST['Menstruatie'];?>" /></td> </tr> <tr> <td align="left" valign="top">Is this date certain?</td> <td align="left" valign="top"><select name="menstruatie_zeker"><option selected="selected" value="ja">>yes</option><option selected="selected" value="nee">>no</option></select></td> </tr> <tr> <td align="left" valign="top">How many pregnancies have you had, including this one??</td> <td align="left" valign="top"><input class="inputtekst" name="zwangerschap" type="text" value="<?=$_POST['zwangerschap'];?>" /></td> </tr> <tr> <td align="left" valign="top">How many children do you have?</td> <td align="left" valign="top"><input class="inputtekst" name="kinderen" type="text" value="<?=$_POST['kinderen'];?>" /></td> </tr> <tr> <td align="left" valign="top">Have you ever had a miscarriage?</td> <td align="left" valign="top"><select name="miskraam"><option selected="selected" value="ja">>yes</option><option selected="selected" value="nee">>no</option></select></td> </tr> <tr> <td align="left" valign="top">Weight (kg)</td> <td align="left" valign="top"><input class="inputtekst" name="gewicht" type="text" value="<?=$_POST['gewicht'];?>" /></td> </tr> <tr> <td align="left" valign="top">Other comments</td> <td align="left" valign="top"><textarea style="height: 100px; width: 300px;" name="opmerkingen"><?=$_POST[‘opmerkingen’];?></textarea></td> </tr> <tr> <td align="left" valign="top"><input name="sent" type="hidden" value="1" /></td> <td align="left" valign="top"><input name="versturen" type="submit" value="send" /></td> </tr> </tbody> </table> </form> <p><? } ?></p> <p>