Form not working now, help needed please!

PHP
1

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 &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" />
	</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>";
  } 
} 

?>
2

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

3

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

4

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

5

Fixed!!! My bad.

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