| Server IP : 10.200.247.200 / Your IP : 216.73.217.19 Web Server : Apache System : Linux synergy-usa-sites 6.8.0-138-generic #138-Ubuntu SMP PREEMPT_DYNAMIC Fri Jul 31 22:41:49 UTC 2026 x86_64 User : jeremy ( 1001) PHP Version : 8.4.25 Disable Function : NONE MySQL : OFF | cURL : ON | WGET : ON | Perl : ON | Python : OFF | Sudo : ON | Pkexec : OFF Directory : /var/www/asap_sites/improvedpatientcare.org/ |
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<?php
require_once "formvalidator.php";
require_once "php/mailgun.php";
if(isset($_POST['Submit']))
{
$validator = new FormValidator();
$validator->addValidation("nam","req","Full Name");
$validator->addValidation("eml","email","Please enter a valid email");
$validator->addValidation("eml","req","Valid Email Address");
$validator->addValidation("ph3","req","Current Valid Phone");
$validator->addValidation("mes","req","Message");
if(!function_exists('PostFields')) {
function PostFields($url,$fields)
{
$fields = http_build_query($fields);
$ch = curl_init();
curl_setopt($ch, CURLOPT_RETURNTRANSFER, 1);
curl_setopt($ch, CURLOPT_FOLLOWLOCATION, 1);
curl_setopt($ch, CURLOPT_REFERER, $_SERVER["HTTP_HOST"] . $_SERVER['REQUEST_URI']);
curl_setopt($ch, CURLOPT_URL, $url);
curl_setopt($ch, CURLOPT_POST, 1);
curl_setopt($ch, CURLOPT_POSTFIELDS, $fields);
curl_setopt($ch, CURLOPT_SSL_VERIFYPEER, FALSE);
curl_setopt($ch, CURLOPT_USERAGENT, "LCAPI cUrl Agent");
curl_setopt($ch, CURLOPT_VERBOSE, true);
ob_start();
$data = curl_exec ($ch);
ob_end_clean();
curl_close ($ch);
return $data;
}
}
$postfields = array();
$postfields['secret'] = '6Ld1puMZAAAAAFokcJIN3GJ47Kgyfbkm5UakfObV';
$postfields['response'] = $_POST['g-recaptcha-response'];
$postfields['remoteip'] = $_SERVER['REMOTE_ADDR'];
$recaptcha_response = PostFields('https://www.google.com/recaptcha/api/siteverify',$postfields);
$json_response = json_decode($recaptcha_response);
$recaptcha_passed = false;
if($json_response->success) {
$recaptcha_passed = true;
}
function isRussian($text) {
return preg_match('/[А-Яа-яЁё]/u', $text);
}
$isSpam = false;
if(isRussian($_POST['mes'])) {
$isSpam = true;
}
if(strpos($_POST['mes'],'talkwithwebvisitors.com')!==false) {
$isSpam = true;
}
if($validator->ValidateForm() && $recaptcha_passed && !$isSpam)
{
//$to = "etoddt@gmail.com";
$to = "cme@improvedpatientcare.org";
$headers = 'From: Improved Patient Care <cme@improvedpatientcare.org>' . "\r\n";
$co = "Improved Patient Care";
$co2 = "Improved Patient Care <cme@improvedpatientcare.org>";
$nam = $_POST['nam'];
$eml = $_POST['eml'];
$ph1 = $_POST['ph1'];
$ph2 = $_POST['ph2'];
$ph3 = $_POST['ph3'];
$sub = $_POST['sub'];
$add = $_POST['add'];
$cit = $_POST['cit'];
$mes = $_POST['mes'];
$dat = date("F j, Y, g:i A");
$body ="
Improved Patient Care - Contact Page: $dat.\n
From: $nam
E-Mail: $eml
Phone: ($ph1) $ph2-$ph3
Address:$add
$cit, $sub
Message:
$mes
";
$body2 ="
Thank you for your interest in Improved Patient Care (ASAP) \n
We received your email on $dat and are processing your inquiry.\n
An ASAP representative will respond within 24-48 hours.\n\n
Below is a copy of the information we receieved.\n
From: $nam
E-Mail: $eml
Phone: ($ph1) $ph2-$ph3
Address:$add
$cit, $sub
Message:
$mes\n
NOTE: DO NOT RESPOND TO THIS EMAIL.\n
Please send all email correspondence to cme@improvedpatientcare.org\n
";
//if(mail($to, $co, $body, "From: $co2")){
mailgun_send_message($to,$co2,$co,nl2br($body),1,'ImprovedPatientCare Contact','','','',0,array(),'',0);
//mail($eml, $co, $body2, $headers);
mailgun_send_message($eml,$co2,$co,nl2br($body2),1,'ImprovedPatientCare Contact','','','',0,array(),'',0);
$output = '<p class="success"><b>THANK YOU FOR YOUR EMAIL!</b> Please allow 24-48 hours for a representative to contact you regarding your inquiry.</p>';
$reset = 'reset';
//}
} else {
$output .= "<p class='error'>";
$output .= "<b>SORRY -</b> We need you to input";
$error_hash = $validator->GetErrors();
if(!$recaptcha_passed) {
$error_hash[] = 'Recaptcha Failed';
}
foreach($error_hash as $inpname => $inp_err)
{
$output .= ", <u>$inp_err</u>";
}
$output .= "</p>";
}
}
$body_id = 'contact';
$title = 'Contact Us';
require_once('header.php'); ?>
<br /><br />
<script src="https://www.google.com/recaptcha/api.js" async defer></script>
<script type="text/javascript" language="javascript">
<!--
function clearForms() {
document.dform.nam.value = '';
document.dform.eml.value = '';
document.dform.ph1.value = '';
document.dform.ph2.value = '';
document.dform.ph3.value = '';
document.dform.add.value = '';
document.dform.cit.value = '';
document.dform.mes.value = '';
document.getElementById('sub').value = '';
}
-->
</script>
<?php print $output;?>
<form name="dform" id="dform" method="post" action="" accept-charset="UTF-8">
<input type="hidden" id="check" value="<?php print $reset?>" onclick="javscript:return clearForms();" />
<center>
<table cellpadding="6" cellspacing="0" border="0" class="form">
<tr>
<td align="right" class="required">Full Name</td>
<td align="left"><input name="nam" type="text" onblur="this.style.color=suces" onfocus="this.style.color=focci"
onKeyUp="javascript:return valName('dform','nam');" value="<?php if (isset($_POST['nam'])){echo htmlspecialchars($_POST['nam'], ENT_QUOTES);}?>" /></td>
</tr>
<tr>
<td align="right" class="required">Email Address</td>
<td align="left"><input name="eml" type="text" onblur="javascript:return valEmail('dform','eml')" value="<?php if (isset($_POST['eml'])){echo htmlspecialchars($_POST['eml'], ENT_QUOTES);}?>" /></td>
</tr>
<tr>
<td align="right" class="required">Phone</td>
<td class="left"><input name="ph1" maxlength="3" type="text" class="phn" onKeyDown="TabNext(this,'down',3)"
onblur="this.style.color=suces" onfocus="this.style.color=focci"
onKeyUp="TabNext(this,'up',3,this.form.ph2);valNum(this)"
value="<?php if (isset($_POST['ph1'])){echo htmlspecialchars($_POST['ph1'], ENT_QUOTES);}?>" />
<input name="ph2" maxlength="3" type="text" class="phn" onKeyDown="TabNext(this,'down',3)"
onblur="this.style.color=suces" onfocus="this.style.color=focci"
onKeyUp="TabNext(this,'up',3,this.form.ph3);valNum(this)"
value="<?php if (isset($_POST['ph2'])){echo htmlspecialchars($_POST['ph2'], ENT_QUOTES);}?>" />
<input name="ph3" maxlength="4" type="text" class="phn2" onKeyUp="valNum(this)"
onblur="this.style.color=suces" onfocus="this.style.color=focci"
value="<?php if (isset($_POST['ph3'])){echo htmlspecialchars($_POST['ph3'], ENT_QUOTES);}?>" />
</td>
</tr>
<tr>
<td align="right">Address</td>
<td align="left"><input name="add" type="text" onblur="this.style.color=suces" onfocus="this.style.color=focci" value="<?php if (isset($_POST['add'])){echo htmlspecialchars($_POST['add'], ENT_QUOTES);}?>" /></td>
</tr>
<tr>
<td align="right">City</td>
<td align="left"><input name="cit" type="text" onblur="this.style.color=suces" onfocus="this.style.color=focci" value="<?php if (isset($_POST['cit'])){echo htmlspecialchars($_POST['cit'], ENT_QUOTES);}?>" /></td>
</tr>
<tr>
<td align="right">State</td>
<td class="left"><select id="sub" name="sub" onblur="this.style.color=suces" onfocus="this.style.color=focci"
onChange="if (dform.sub[dform.sub.selectedIndex].value === '') {alert('Please choose an option.'); return false;};">
<option value="" selected="selected"></option>
<option value="AL" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'AL') {echo 'selected="selected"';} ?>>AL</option>
<option value="AK" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'AK') {echo 'selected="selected"';} ?>>AK</option>
<option value="AZ" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'AZ') {echo 'selected="selected"';} ?>>AZ</option>
<option value="AR" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'AR') {echo 'selected="selected"';} ?>>AR</option>
<option value="CA" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'CA') {echo 'selected="selected"';} ?>>CA</option>
<option value="CO" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'CO') {echo 'selected="selected"';} ?>>CO</option>
<option value="CT" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'CT') {echo 'selected="selected"';} ?>>CT</option>
<option value="DE" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'DE') {echo 'selected="selected"';} ?>>DE</option>
<option value="DC" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'DE') {echo 'selected="selected"';} ?>>DC</option>
<option value="FL" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'FL') {echo 'selected="selected"';} ?>>FL</option>
<option value="GA" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'GA') {echo 'selected="selected"';} ?>>GA</option>
<option value="HI" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'HI') {echo 'selected="selected"';} ?>>HI</option>
<option value="ID" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'ID') {echo 'selected="selected"';} ?>>ID</option>
<option value="IL" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'IL') {echo 'selected="selected"';} ?>>IL</option>
<option value="IN" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'IN') {echo 'selected="selected"';} ?>>IN</option>
<option value="IA" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'IA') {echo 'selected="selected"';} ?>>IA</option>
<option value="KS" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'KS') {echo 'selected="selected"';} ?>>KS</option>
<option value="KY" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'KY') {echo 'selected="selected"';} ?>>KY</option>
<option value="LA" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'LA') {echo 'selected="selected"';} ?>>LA</option>
<option value="ME" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'ME') {echo 'selected="selected"';} ?>>ME</option>
<option value="MD" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'MD') {echo 'selected="selected"';} ?>>MD</option>
<option value="MA" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'MA') {echo 'selected="selected"';} ?>>MA</option>
<option value="MI" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'MI') {echo 'selected="selected"';} ?>>MI</option>
<option value="MN" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'MN') {echo 'selected="selected"';} ?>>MN</option>
<option value="MS" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'MS') {echo 'selected="selected"';} ?>>MS</option>
<option value="MO" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'MO') {echo 'selected="selected"';} ?>>MO</option>
<option value="MT" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'MT') {echo 'selected="selected"';} ?>>MT</option>
<option value="NE" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'NE') {echo 'selected="selected"';} ?>>NE</option>
<option value="NV" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'NV') {echo 'selected="selected"';} ?>>NV</option>
<option value="NH" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'NH') {echo 'selected="selected"';} ?>>NH</option>
<option value="NJ" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'NJ') {echo 'selected="selected"';} ?>>NJ</option>
<option value="NM" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'NM') {echo 'selected="selected"';} ?>>NM</option>
<option value="NY" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'NY') {echo 'selected="selected"';} ?>>NY</option>
<option value="NC" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'NC') {echo 'selected="selected"';} ?>>NC</option>
<option value="ND" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'ND') {echo 'selected="selected"';} ?>>ND</option>
<option value="OH" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'OH') {echo 'selected="selected"';} ?>>OH</option>
<option value="OK" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'OK') {echo 'selected="selected"';} ?>>OK</option>
<option value="OR" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'OR') {echo 'selected="selected"';} ?>>OR</option>
<option value="PA" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'PA') {echo 'selected="selected"';} ?>>PA</option>
<option value="RI" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'RI') {echo 'selected="selected"';} ?>>RI</option>
<option value="SC" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'SC') {echo 'selected="selected"';} ?>>SC</option>
<option value="SD" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'SD') {echo 'selected="selected"';} ?>>SD</option>
<option value="TN" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'TN') {echo 'selected="selected"';} ?>>TN</option>
<option value="TX" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'TX') {echo 'selected="selected"';} ?>>TX</option>
<option value="UT" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'UT') {echo 'selected="selected"';} ?>>UT</option>
<option value="VT" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'VT') {echo 'selected="selected"';} ?>>VT</option>
<option value="VA" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'VA') {echo 'selected="selected"';} ?>>VA</option>
<option value="WA" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'WA') {echo 'selected="selected"';} ?>>WA</option>
<option value="WV" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'WV') {echo 'selected="selected"';} ?>>WV</option>
<option value="WI" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'WI') {echo 'selected="selected"';} ?>>WI</option>
<option value="WY" <?php if (isset($_POST['sub']) && $_POST['sub'] == 'WY') {echo 'selected="selected"';} ?>>WY</option>
</select>
</td>
</tr>
<tr>
<td align="right" class="required">Message</td>
<td align="left"><textarea name="mes" onblur="this.style.color=suces" onfocus="this.style.color=focci" class="input_text"><?php if (isset($_POST['mes'])){echo htmlspecialchars($_POST['mes'], ENT_QUOTES);}?></textarea></td>
</tr>
<tr>
<td colspan="4" align="center">
<script type="text/javascript" language="javascript">
<!--
onload = function() {
if(document.getElementById('check').value != '') {
setTimeout('clearForms()', 200);
}
}
-->
</script>
<center>
<div class="g-recaptcha" data-sitekey="6Ld1puMZAAAAAL1ZV0af75SEkqkA5g9DvJg9ZSyD"></div>
</center>
<center>
<input type="submit" name="Submit" class="submit" value="Submit Email" onmouseover="this.style.backgroundPosition='top center'" onmouseout="this.style.backgroundPosition='bottom center'" />
</center>
</td>
</tr>
</table>
<center><img src="images/img_asap_address.png" border="0" vspace="15" /></center>
<? require_once('footer.php'); ?>