<%@ Language=VBScript %> Request Information <% Dim sEmailAddr, sMsg Dim sBodyRecpt1, sBodyRecpt2, sBodyRecpt3, sBodyRecpt4, sBodyRecpt5, sBodyRecpt6, sBodyRecpt7, sBodyRecpt8 Dim sBodyRecpt9, sBodyRecpt10, sBodyRecpt11, sBodyRecpt12, sBodyRecpt13 Dim sNameValue, sCompanyValue, taAddressValue, sCountryValue, sCityValue, sZipCodeValue, sStateValue Dim sNumber, sFax, sWebLink, sRadioOther , sRadioChoice Dim sbox1, sbox2, sbox3, sbox4, sbox5, sbox6, sbox7, sbox8, sbox9, sbox10, sbox11, sbox12 Dim taCommentField On Error Resume Next sEmailAddr = Request.Form("EmailAddress") sNameValue = Request.Form("lastandfirstname") sCompanyValue = Request.Form("companyname") taAddressValue = Request.Form("companyaddress") sCountryValue = Request.Form("countryname") sCityValue = Request.Form("cityname") sZipCodeValue = Request.Form("zipcode") sStateValue = Request.Form("statename") sNumber = Request.Form("phonenumber") sFax = Request.Form("faxnumber") sWebLink = Request.Form("website") sRadioOther = Request.Form("otherinterest") sbox1 = Request.Form("box1") sbox2 = Request.Form("box2") sbox3 = Request.Form("box3") sbox4 = Request.Form("box4") sbox5 = Request.Form("box5") sbox6 = Request.Form("box6") sbox7 = Request.Form("box7") sbox8 = Request.Form("box8") sbox9 = Request.Form("box9") sbox10 = Request.Form("box10") sbox11 = Request.Form("box11") sbox12 = Request.Form("box12") taCommentField = Request.Form("textarea") Select Case Request.Form("interest") Case "1" sRadioChoice = "Patient" Case "2" sRadioChoice = "Research/Student" Case "3" sRadioChoice = "EMS/EMT" Case "4" sRadioChoice = "Distributor" Case "5" sRadioChoice = "Doctor" Case "6" sRadioChoice = "Pharmacy" Case "7" sRadioChoice = "RN" Case "8" sRadioChoice = "Homecare Dealer" Case "9" sRadioChoice = "Educator" Case "10" sRadioChoice = "Manufacturer" End Select If Len(sbox1) = 0 Then sbox1 = "(u/c)" End If If Len(sbox2) = 0 Then sbox2 = "(u/c)" End If If Len(sbox3) = 0 Then sbox3 = "(u/c)" End If If Len(sbox4) = 0 Then sbox4 = "(u/c)" End If If Len(sbox5) = 0 Then sbox5 = "(u/c)" End If If Len(sbox6) = 0 Then sbox6 = "(u/c)" End If If Len(sbox7) = 0 Then sbox7 = "(u/c)" End If If Len(sbox8) = 0 Then sbox8 = "(u/c)" End If If Len(sbox9) = 0 Then sbox9 = "(u/c)" End If If Len(sbox10) = 0 Then sbox10 = "(u/c)" End If If Len(sbox11) = 0 Then sbox11 = "(u/c)" End If If Len(sbox12) = 0 Then sbox12 = "(u/c)" End If If Len(sEmailAddr) > 0 Then sBodyRecpt1 = "Name :" & VBTab & VBTab & sNameValue & VBCrLf sBodyRecpt2 = "company :" & VBTab & sCompanyValue & VBCrLf & VBCrLf & "Address :" & VBCrLf sBodyRecpt3 = taAddressValue sBodyRecpt4 = VBCrLf & VBCrLf & "City:" & VBTab& VBTab & sCountryValue & VBCrLf & "state:" & VBTab & VBTab & sStateValue sBodyRecpt5 = VBCrLf & "Zip Code:" & VBTab & sZipCodeValue & VBCrLf & "Country:" & VBTab & sCityValue sBodyRecpt6 = VBCrLf & "Phone Number:" & VBTab & sNumber & VBCrLf & "Fax Number:" & VBTab & sFax sBodyRecpt7 = VBCrLf & "Email: " & VBTab & VBTab & sEmailAddr & VBCrLf & "Website:" & VBTab & sWebLink sBodyRecpt8 = VBCrLf & VBCrLf &"Interested as a: " & VBTab & sRadioChoice & VBCrLf & "other : (" & sRadioOther & ")" sBodyRecpt9 = VBCrLf & VBCrLf & "[human]" & VBCrLf & "Patient Monitors " & VBTab & sbox1 & VBCrLf sBodyRecpt10= "Pulse Oximeters " & VBTab & sbox2 & VBCrLf & "Digital Thermometers " & VBTab & sbox3 & VBCrLf & "Pulse Oximeter Sensors " & VBTab & sbox4 & VBCrLf sBodyRecpt11= "OEM Technologies " & VBTab & sbox5 & VBCrLf & "Software " & VBTab & VBTab & sbox6 & VBCrLf & VBCrLf & "[veterinary]" & VBTab & VBCrLf & "Monitor " & VBTab & VBTab & sbox7 & VBCrLf sBodyRecpt12= "Pulse Oximeters " & VBTab & sbox8 & VBCrLf & "Pulse Oximeter Sensors " & VBTab & sbox9 & VBCrLf & "ECG " & VBTab & VBTab & VBTab & sbox10 & VBCrLf & VBCrLf sBodyRecpt13= "[Software]" & VBCrLf & "Oxysoft " & VBTab & VBTab & sbox11 & VBCrLf & "Accessories " & VBTab & VBTab & sbox12 & VBCrLf & VBCrLf & "Comments or additional questions:" & VBCrLf & "=================================================" & VBCrLf Call SendEmail End If If Err.number <> 0 Then sMsg = Err.Description End If Sub SendEmail() Dim oMail On Error Resume Next Set oMail = Server.CreateObject("CDONTS.NewMail") With oMail .From = sEmailAddr .To = "info@mediaidinc.com" .Subject = "Info Request : Mediaid Inc Website" .Body = sBodyRecpt1 & sBodyRecpt2 & sBodyRecpt3 & sBodyRecpt4 & sBodyRecpt5 & sBodyRecpt6 & sBodyRecpt7 & sBodyRecpt8 & sBodyRecpt9 & sBodyRecpt10 & sBodyRecpt11 & sBodyRecpt12 & sBodyRecpt13 & taCommentField .Send End With Set oMail = Nothing If Err.number <> 0 Then sMsg = Err.Description Err.Clear End If End Sub %>

Request Information

<%If Len(sEmailAddr) > 0 And Len(sMsg) = 0 Then%> Thank you for your interest in our products. Your e-mail was sent successfully.
        click here to start over <%Else%> (NOTE: You must include an email address )

<%End If%>

Name

Company

Address

City

State

Zip Code

Country

Phone

Fax

E-mail

Website

My interest is as a:

Patient

Research/Student

EMS/EMT

Distributor

Doctor

Pharmacy

RN

Homecare Dealer

Educator

Manufacturer

 

Other

Please check all that apply:

Human

 

Patient Monitors

Pulse Oximeters

Digital Thermometers

Pulse Oximeter Sensors

OEM Technologies

Software

 

 

Veterinary

 

Monitor

Pulse Oximeters

Pulse Oximeter Sensors

ECG

 

 

Software

 

Oxysoft

 

 

 

Accessories

 

Comments or additional questions: