Form not working now, help needed please!

An order form I was making is no longer working, the link is here:

I tried adding in the pickup option thing and since then it has not worked since.

Any ideas why?

<form method="post" action="mailer.php">
    <div id="form_left">
              Your Name:<br /><br />
   <input type="text" name="name" size="24" /><br />
   <br />
   <br />
    Your Email:<br /><br />
   <input type="text" name="email" size="24" />
 <div id="form_right">
Your Date of Birth:<br /><br />
  <input type="text" name="dob" size="24" /><br />
  <br />

    <div id="form_left2"><br /><br />
 National Insurance Number:<br /><br />
  <input type="text" name="nin" size="24" /><br />
    <br /><br />
  <br />

    <div id="form_right2">
   Prescription Pickup Point:<br /><br />
    <select name="pickup">
    <option>K1 Boots Cushendall Road</option>
    <option>K2 Boots Tower Centre</option>
    <option>K3 Sainsburys</option>
    <option>K4 Dunclug</option>
    <option>K5 Lloyds</option>
    <option>K6 Boots Harryville</option>
    <option>K7 Woodsides</option>
    <option>K8 Broughshane</option>
    <option>K9 Kells</option>
    <option>K10 Simpsons Galgorm</option>
    <option>K11 Ahoghill</option>
    <option>K12 Boots Cullybackey</option>
    <option>K13 Ballykell</option>
    <option>K14 Ballee</option>




   <p>Please specify the details of your order, including name &amp; quantity :</p>
   <textarea rows="10" name="message" cols="55"></textarea>
   <br />
         <p>Please ensure that you have filled out all important information before submitting.</p>
         <p><b>You must provide photographic ID when picking up your order.</b></p>

 <br />
    <input type="submit" value="Submit" name="submit" />

if (isset($_POST['submit'])) {
  $subject = "Prescription Order";
  $name_field = $_POST['name'];
  $email_field = $_POST['email'];
  $dob_field = $_POST['dob'];
  $pickup = $_POST['pickup'];
  $nin = $_POST['nin'];
  $headers = "MIME-Version: 1.0\
  $headers .= "Content-type: text/plain; charset=iso-8859-1\
  $headers .= "From: Mark <> \
  $headers .= "X-Mailer: PHP's mail() Function\

  $message = $_POST['message'];
  if (strlen(trim($message)) > 0) {
    $body = "From: $name_field\
 E-Mail: $email_field\
 Date of birth: $dob_field\
 Pickup: $pickup\
 National Insurance Number: $nin\
  Message: $message\
    if (mail($to, $subject, $body, $headers)) {
      echo "<h3>Thanks! Your email has been sent <br />We will process your order as soon as possible.</h3>";
    } else {
      echo 'Cannot sent mail';
  } else {
    echo "<h3>Error! <br />Please ensure that all fields are filled out in order to email us!</h3>";


What isn’t working? Or more precisely, what are you expecting it to do that it isn’t doing?

And there is no checking of user input = Email SPAM Hell!

By validating user input (form data) before you use it. :wink:

Fixed!!! My bad.

Siteguru - how can I prevent email spam from my form?