An order form I was making is no longer working, the link is here:
http://mgdesign.hostultra.com/GP_Edit/repeat_prescriptions.html
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>
<div id="form_right">
Your Date of Birth:<br /><br />
<input type="text" name="dob" size="24" /><br />
<br />
</div>
<div id="form_left2"><br /><br />
National Insurance Number:<br /><br />
<input type="text" name="nin" size="24" /><br />
<br /><br />
</div>
<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>
</select>
</div>
<p>Please specify the details of your order, including name & 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" />
</form>
<?php
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 <mark365@hotmail.com> \
";
$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>";
}
}
?>