I need to find out how to put database fields into an email form as well as add radio buttons, drop down boxes, etc. I have some basic textarea boxes in the form part so far. Here is my code. The upper half of the page shows a search result and the lower half is a form that my client can notify us of changes they would like to make to a specific account. Any help is appreciated. Thanks.
<?
$link=mysql_connect('host', 'database', 'password');
if (!$link) {
die('Could not connect: ' .mysql_error());
}
else
{
// Connected to the database
print("<table border=1 cellpadding=2 cellspacing=2 valign=top align=center width=800><td width=100% colspan=4><font face=arial size=6><b>Crossroads Health Care Management Web Portal</font></b></td><tr>\n");
}
@mysql_select_db( "dcscol") or die( "Unable to select database");
$cliacct=$_POST['clientnum'];
$query = "SELECT dcs, cliref, guar, pat, addr1, addr2, city, st, zip, social, dob, phone, dbal, tbal, paid FROM crossroads10 WHERE cliref='$cliacct'";
$result=mysql_query($query);
if (!$result) {
$message = 'Invalid query: ' . mysql_error() . "\n";
$message .= 'Whole query: ' . $query;
die($message);
}
while ($row = mysql_fetch_assoc($result)) {
$dcs = $row['dcs'];
$cliref = $row['cliref'];
$guarantor = $row['guar'];
$patient = $row['pat'];
$address1 = $row['addr1'];
$address2 = $row['addr2'];
$city = $row['city'];
$state = $row['st'];
$zip = $row['zip'];
$social = $row['social'];
$dob = $row['dob'];
$phone = $row['phone'];
$ticketbal = $row['dbal'];
$totalbal = $row['tbal'];
$paid = $row['paid'];
print ("<td bgcolor=#003399 width=50% colspan=2><font face=arial size=2 color=#ffffff> Results for Client Account Number:<b> $cliacct</b></font></td><td bgcolor=#003399 width=50% colspan=2 align=center><font face=arial size=1 color=#ffffff>Provided By: Diversified Credit Systems (800) 256-3838</td><tr>");
print ("<td width=25% bgcolor=#666666><font face=arial size=2 color=#ffffff><b> DCS Account Number:</b></font></td><td width=25%><font face=arial size=2 color=#000000> $dcs</font></td>");
print ("<td width=25% bgcolor=#666666><font face=arial size=2 color=#ffffff><b>Client Account Number:</b></font></td><td width=25%><font face=arial size=2 color=#000000> $cliref</font></td><tr>");
print ("<td width=25% bgcolor=#666666><font face=arial size=2 color=#ffffff><b> Responsible Party:</b></font></td><td width=25%><font face=arial size=2 color=#000000> $guarantor</font></td>");
print ("<td width=25% bgcolor=#666666><font face=arial size=2 color=#ffffff><b> Patient: </b></font></td><td width=25%><font face=arial size=2 color=#000000> $patient</font></td><tr>");
print ("<td width=25% bgcolor=#666666><font face=arial size=2 color=#ffffff><b> Address: </b></font></td><td width=25%><font face=arial size=2 color=#000000>$address1</font></td>");
print ("<td width=25% bgcolor=#666666><font face=arial size=2 color=#ffffff><b> Address Line 2: </b></font></td><td width=25%><font face=arial size=2 color=#000000>$address2</font></td><tr>");
print ("<td width=100% colspan=4><table border=0 width=100% colspan=4><td width=16% bgcolor=#666666><font face=arial size=2 color=#ffffff><b>City</b></font></td><td width=16%><font face=arial size=2 color=#000000> $city </td><td width=16% bgcolor=#666666><font face=arial size=2 color=#ffffff><b>State</b></font></td><td width=16%><font face=arial size=2 color=#000000> $state</td><td width=16% bgcolor=#666666><font face=arial size=2 color=#ffffff><b>Zip Code</b></td><td width=16%><font face=arial size=2 color=#000000> $zip</font></td></table></td><tr>");
print ("<td width=25% bgcolor=#666666><font face=arial size=2 color=#ffffff><b> Social Security Number:</b></font></td><td width=25%><font face=arial size=2 color=#000000> $social</font></td>");
print ("<td width=25% bgcolor=#666666><font face=arial size=2 color=#ffffff><b> Date of Birth:</b></font></td><td width=25%><font face=arial size=2 color=#000000> $dob</font></td><tr>");
print ("<td width=50% colspan=2 bgcolor=#666666><font face=arial size=2 color=#ffffff><b>Phone:</b></font></td><td width=50% colspan=2><font face=arial size=2 color=#000000> $phone</font></td><tr>");
print ("<td width=100% colspan=4><table border=0 width=100% colspan=4><td width=16% bgcolor=#666666><font face=arial size=2 color=#ffffff><b> Encounter Balance: </b></font></td><td width=16%><font face=arial size=2 color=#000000>$ticketbal</font></td>");
print ("<td width=16% bgcolor=#666666><font face=arial size=2 color=#ffffff><b>Total Due:</b></font></td><td width=16%><font face=arial size=2 color=#000000> $totalbal</font></td>");
print ("<td width=16% bgcolor=#666666><font face=arial size=2 color=#ffffff><b>Total Paid:</b></font></td><td width=16%><font face=arial size=2 color=#000000> $paid</font></td></tr></table></td></tr>");
}
if (($Name == "") || ($Email == "") || ($Comments == ""))
{
echo "<td width=100% colspan=4><font face=arial size=2><form name=form method=post action=contact_thanks.php>";
echo "<p class=bodymd><b>Account Actions & Changes</b></p>";
}
if ($Name == "")
{
echo "<p class=bodymd>Your Name<br><input type=text name=Name></p>";
}
else
{
echo "<input type=hidden name=Name value=$Name>";
}
if ($Email == "")
{
echo "<p class=bodymd>Your Email<br><input type=text name=Email></p>";
}
else
{
echo "<input type=hidden name=Email value=$Email>";
}
if ($Comments == "")
{
echo "<p class=bodymd>Comments or Questions<br><textarea name=Comments rows=5 cols=40></textarea></p>";
}
else
{
echo "<input type=hidden name=Comments value=$Comments>";
}
if (($Name == "") || ($Email == "") || ($Comments == ""))
{
echo "<input type=submit name=Submit value=Submit>";
echo "<input type=reset name=Reset value=Clear Form>";
echo "</form></font></td></tr></table>";
}
else
{
$message = "Name: $Name\nEmail: $Email\nComments: $Comments\n";
$extra = "From: $Name\r\nReply-To: $Email\r\n";
mail ("noone@nowhere.com", "Website Email", $message, $extra);
echo "<p class=bodymd>Thanks for your inguiry, $Name.</p>";
echo "<p class=bodymd>A response will be sent to $Email as soon as possible.</p>";
}
?>
