You are here : Home / Refer a Patient to Indian IVF Clinics for IVF and Surrogacy
Text :
Are you a Gynaecologist, a General Practitioner, or are you involved in the healthcare service industry in your country?
Do you want to refer a patient for IVF, Fertility, Egg Donation, Surrogacy or any other treatment in India.
If Yes, Please fill the given form and send us immediately:
<%
cTemp = recaptcha_confirm(recaptcha_private_key, recaptcha_challenge_field, recaptcha_response_field)
If cTemp <> "" Then
%>
An error occured with the recapture wording. Please try again. The error was Invalid Captcha Code
<% Else %>
<%
getemail=trim(Request.Form("email"))
Dim iMsg
Dim iConf
Dim Flds
Dim strHTML
Dim strSmartHost
dim email
email=Request.Form("email")
Const cdoSendUsingPort = 1
StrSmartHost = "mail.gmail.com"
set iMsg = CreateObject("CDO.Message")
set iConf = CreateObject("CDO.Configuration")
dim strmess
strmess="Query Form from IVF Surrogacy "
strmess=strmess & " Contact Message "
strmess=strmess & " Details of "& Request.Form("namep") & " "
strmess=strmess & " Your Name : "& Request.Form("namep") & ""
strmess=strmess & " Gender : "& Request.Form("gender") & ""
strmess=strmess & " Email : "& email
strmess=strmess & " Telephone Number : "& Request.Form("intcode") & ""
strmess=strmess & " - "& Request.Form("areacode") & ""
strmess=strmess & " - "& Request.Form("phoneno") & ""
strmess=strmess & " Mobile Number : "& Request.Form("mobileintcode") & ""
strmess=strmess & " - "& Request.Form("mobile") & ""
strmess=strmess & " City : "& Request.Form("city") & ""
strmess=strmess & " State : "& Request.Form("state") & ""
strmess=strmess & " Country : "& Request.Form("country") & ""
strmess=strmess & " Address : "& Request.Form("address") & ""
strmess=strmess & " Your Message : "& Request.Form("comments") & "
"
strmess=strmess & " "& Request.Form("patientname") & " Details "
strmess=strmess & " Name : "& Request.Form("patientname") & ""
strmess=strmess & " Gender : "& Request.Form("patientgender") & ""
strmess=strmess & " Email : "& Request.Form("patientemail") & ""
strmess=strmess & " Telephone Number : "& Request.Form("patientintcode") & ""
strmess=strmess & " - "& Request.Form("patientareacode") & ""
strmess=strmess & " - "& Request.Form("patientphone") & ""
strmess=strmess & " Mobile Number : "& Request.Form("patientmobileintcode") & ""
strmess=strmess & " - "& Request.Form("patientmobileno") & ""
strmess=strmess & " City : "& Request.Form("patientcity") & ""
strmess=strmess & " State : "& Request.Form("patientstate") & ""
strmess=strmess & " Country : "& Request.Form("patientcountry") & ""
strmess=strmess & " Address : "& Request.Form("patientaddress") & ""
strmess=strmess & " Your Message : "& Request.Form("patientcomments") & ""
strmess=strmess & " Clinical Status of the patient : "& Request.Form("status") & ""
strmess=strmess & " Treatment Looking for : "& Request.Form("lookfor") & ""
Set Flds = iConf.Fields
With Flds
.Item("http://schemas.microsoft.com/cdo/configuration/sendusing") = cdoSendUsingPort
.Item("http://schemas.microsoft.com/cdo/configuration/smtpserver") = strSmartHost
.Item("http://schemas.microsoft.com/cdo/configuration/sendusername") = "info.wecareindia"
.Item("http://schemas.microsoft.com/cdo/configuration/sendpassword") = "paperpaper"
.Item("http://schemas.microsoft.com/cdo/configuration/smtpconnectiontimeout") = 10
.Item("http://schemas.microsoft.com/cdo/configuration/smtpserverport") = 26
.Item("http://schemas.microsoft.com/cdo/configuration/smtpauthenticate") = 1
.Item("http://schemas.microsoft.com/cdo/configuration/smtpserverpickupdirectory")="C:\Inetpub\mailroot\Pickup"
.Update
End With
' apply the settings to the message
With iMsg
Set .Configuration = iConf
.To = "info.wecareindia@gmail.com"
.BCC = "info.wecareindia@gmail.com"
'.From = getemail
.From = email
'.From = "info.wecareindia@gmail.com"
.Subject = "Query Form from IVF Surrogacy"
.HTMLBody = strmess
.Send
End With
' cleanup of variables
Set iMsg = Nothing
Set iConf = Nothing
Set Flds = Nothing
Response.Redirect("thanks.htm")
%>
<% End If %>
<%
' The code below supplied by Mark Short
' returns string the can be written where you would like the reCAPTCHA challenged placed on your page
function recaptcha_challenge_writer(publickey)
recaptcha_challenge_writer = "" & _
"" & _
""
end function
function recaptcha_confirm(privkey,rechallenge,reresponse)
' Test the captcha field
Dim VarString
VarString = _
"privatekey=" & privkey & _
"&remoteip=" & Request.ServerVariables("REMOTE_ADDR") & _
"&challenge=" & rechallenge & _
"&response=" & reresponse
Dim objXmlHttp
Set objXmlHttp = Server.CreateObject("Msxml2.ServerXMLHTTP")
objXmlHttp.open "POST", "http://api-verify.recaptcha.net/verify", False
objXmlHttp.setRequestHeader "Content-Type", "application/x-www-form-urlencoded"
objXmlHttp.send VarString
Dim ResponseString
ResponseString = split(objXmlHttp.responseText, vblf)
Set objXmlHttp = Nothing
if ResponseString(0) = "true" then
' They answered correctly
recaptcha_confirm = ""
else
' They answered incorrectly
recaptcha_confirm = ResponseString(1)
end if
end function
%>
We will contact you within 48 hrs of the receipt of this form on your phone number to have a personal discussion and facilitate for treatment in India.
For more information, medical assessment and medical quote
send your detailed medical history and medical reports
as email attachment to
Em@il : - info@wecareindia.com
Call: +91 9029304141 (10 am. To 8 pm. IST)
(Only for international patients seeking treatment in India)
You are here : Home / Refer a Patient to Indian IVF Clinics for IVF and Surrogacy