"; //$msg = "We have also stored a copy in our database for latter access if necessary. \n\n"; foreach($_GET as $tmpname => $tmpvalue) { if(strcmp($tmpname,"PID") && strcmp($tmpname,"CompanyID") && strcmp($tmpname,"IsData")){ $msg .= "".$tmpname.": \t".trim($tmpvalue)."

"; } } $recipient = ""; // set up mail class $mail = new PHPMailer(); $mail->IsSMTP(); // send via SMTP $mail->Host = "mail.megagate.com"; // example .... smtpout.secureserver.net"; // SMTP servers $mail->SMTPAuth = false; // turn on SMTP authentication $mail->Username = ""; // SMTP username $mail->Password = ""; // SMTP password $mail->From = "webform@wilsonattorney.com"; $mail->FromName = "Personal Injury"; $mail->AddAddress("lawfirm@wilsonattorney.com","Claims"); $mail->WordWrap = 50; // set word wrap $mail->IsHTML(true); // send as HTML $mail->Subject = "Data Submitted to Wilson Law Firm"; $mail->Body = $msg; $mail->AltBody = "This is data submitted from the website"; $mail->Send(); } } ?>
Thank you for completing this brief information form.

When we receive your information we will review it and contact you as soon as possible.
Personal Injury Form
Full Name
Telephone Number
Alternate Number
Mailing Address
Where did the accident occur?
What was the date of the accident?
Did you leave the scene in an ambulance?
What are your injuries?
Were you admitted to a Hospital?
If Yes,
Date of admission?
Date of Discharge?
Are you still under the care of a physician?
Did the authorities assign fault to anyone?
If yes, to who?
Was there a vehicle involved?
How many people were in the vehicle?
Did the driver of the other vehicle have insurance?
Do you have insurance?
E-Mail address