contact.php

<?php include_once('validation.php')?>
<?php include_once('headerform.php')?>


    <form action="contact.php" method="post" class="cmxform">
      <?php
      if ( isset($aErrors) and count($aErrors) > 0 ) {
        print '<ul class="errorlist">';
        foreach ( $aErrors as $error ) {
          print '<li>' . $error . '</li>';
        }
        print '</ul>';
      }
      ?>
      <p>Vul het onderstaand formulier in de verplichte velden zijn met * gemarkeerd <em>*</em></p>
      <fieldset>
        <legend>Gegevens eigenaar</legend>
        <ol>
          <?php echo isset($aErrors['name']) ? '<li class="error">' : '<li>' ?>
            <label for="name">Naam<em>*</em></label>
            <input id="name" name="name" value="<?php echo isset($_POST['name']) ? htmlspecialchars($_POST['name']) : '' ?>" />
          </li>
          <?php echo isset($aErrors['lastname']) ? '<li class="error">' : '<li>' ?>
            <label for="lastname">Achternaam<em>*</em></label>
            <input id="lastname" name="lastname" value="<?php echo isset($_POST['lastname']) ? htmlspecialchars($_POST['lastname']) : '' ?>" />
          </li>

          <?php echo isset($aErrors['email']) ? '<li class="error">' : '<li>' ?>
            <label for="email">E-mail<em>*</em></label>
            <input id="email" name="email" value="<?php echo isset($_POST['email']) ? htmlspecialchars($_POST['email']) : '' ?>" />
          </li>
          <?php echo isset($aErrors['address1']) ? '<li class="error">' : '<li>' ?>
            <label for="address1">Address<em>*</em></label>
            <input id="address1" name="address1" value="<?php echo isset($_POST['address1']) ? htmlspecialchars($_POST['address1']) : '' ?>" />
          </li>
          <?php echo isset($aErrors['towncity']) ? '<li class="error">' : '<li>' ?>
            <label for="towncity">Plaats<em>*</em></label>
            <input id="towncity" name="towncity" value="<?php echo isset($_POST['towncity']) ? htmlspecialchars($_POST['towncity']) : '' ?>" />
          </li>
          <?php echo isset($aErrors['postcode']) ? '<li class="error">' : '<li>' ?>
            <label for="postcode">PostCode<em>*</em></label>
            <input id="postcode" name="postcode" value="<?php echo isset($_POST['postcode']) ? htmlspecialchars($_POST['postcode']) : '' ?>" />
          </li>
          <?php echo isset($aErrors['phone']) ? '<li class="error">' : '<li>' ?>
            <label for="phone">telefoon/gsm<em>*</em></label>
            <input id="phone" name="phone" value="<?php echo isset($_POST['phone']) ? htmlspecialchars($_POST['phone']) : '' ?>" />
          </li>
       </ol>
      </fieldset>
    <fieldset>
    <legend>Gegevens van de hond</legend>
      <ol>
        <?php echo isset($aErrors['dogname']) ? '<li class="error">' : '<li>' ?>
        <label for="dogname">Naam<em>*</em></label>
        <input id="dogname" name="dogname" value="<?php echo isset($_POST['dogname']) ? htmlspecialchars($_POST['dogname']) : '' ?>" />
        </li>
        <?php echo isset($aErrors['chip']) ? '<li class="error">' : '<li>' ?>
        <label for="chip">Chipnr/tatouage<em>*</em></label>
        <input id="chip" name="chip" value="<?php echo isset($_POST['chip']) ? htmlspecialchars($_POST['chip']) : '' ?>" />
        </li>
        <?php echo isset($aErrors['ras']) ? '<li class="error">' : '<li>' ?>
        <label for="ras">Ras<em>*</em></label>
        <input id="ras" name="ras" value="<?php echo isset($_POST['ras']) ? htmlspecialchars($_POST['ras']) : '' ?>" />
        </li>
        <?php echo isset($aErrors['weight']) ? '<li class="error">' : '<li>' ?>
        <label for="weight">gewicht<em>*</em></label>
        <input id="weight" name="weight" value="<?php echo isset($_POST['weight']) ? htmlspecialchars($_POST['weight']) : '' ?>" />
        </li>
        <?php echo isset($aErrors['gender']) ? '<li class="error">' : '<li>' ?>
            <label for="gender" >geslacht<em>*</em></label>
            <input type="radio" name="gender" id="genderM" value="Reu"<?php echo ( isset($_POST['gender']) and $_POST['gender'] == 'Reu' ) ? ' checked="checked"' : '' ?> /> Reu
            <input type="radio" name="gender" id="genderF" value="Teef"<?php echo ( isset($_POST['gender']) and $_POST['gender'] == 'Teef' ) ? ' checked="checked"' : '' ?> /> Teefje
            </li>
            <?php echo isset($aErrors['dinner']) ? '<li class="error">' : '<li>' ?>
            <label for="dinner" >eet 1x/2x per dag<em>*</em></label>
            <input type="radio" name="dinner" id="dinner1" value="1x"<?php echo ( isset($_POST['dinner']) and $_POST['dinner'] == '1x' ) ? ' checked="checked"' : '' ?> /> 1x
            <input type="radio" name="dinner" id="dinner2" value="2x"<?php echo ( isset($_POST['dinner']) and $_POST['dinner'] == '2x' ) ? ' checked="checked"' : '' ?> /> 2x
            </li>
            <?php echo isset($aErrors['socialdog']) ? '<li class="error">' : '<li>' ?>
            <label for="socialdog" >Sociaal met honden<em>*</em></label>
            <input type="radio" name="socialdog" id="socialdogY" value="j"<?php echo ( isset($_POST['socialdog']) and $_POST['socialdog'] == 'j' ) ? ' checked="checked"' : '' ?> /> Ja
            <input type="radio" name="socialdog" id="socialdogN" value="n"<?php echo ( isset($_POST['socialdog']) and $_POST['socialdog'] == 'n' ) ? ' checked="checked"' : '' ?> /> Nee
            </li>
            <?php echo isset($aErrors['socialhuman']) ? '<li class="error">' : '<li>' ?>
            <label for="socialhuman" >Sociaal met mensen<em>*</em></label>
            <input type="radio" name="socialhuman" id="socialhumanY" value="j"<?php echo ( isset($_POST['socialhuman']) and $_POST['socialhuman'] == 'j' ) ? ' checked="checked"' : '' ?> /> Ja
            <input type="radio" name="socialhuman" id="socialhumanN" value="n"<?php echo ( isset($_POST['socialhuman']) and $_POST['socialhuman'] == 'n' ) ? ' checked="checked"' : '' ?> /> Nee
            </li>
            <?php echo isset($aErrors['flea']) ? '<li class="error">' : '<li>' ?>
            <label for="flea" >Ontvlooid<em>*</em></label>
            <input type="radio" name="flea" id="fleaY" value="j"<?php echo ( isset($_POST['flea']) and $_POST['flea'] == 'j' ) ? ' checked="checked"' : '' ?> /> Ja
            <input type="radio" name="flea" id="fleaN" value="n"<?php echo ( isset($_POST['flea']) and $_POST['flea'] == 'n' ) ? ' checked="checked"' : '' ?> /> Nee
            </li>
    </fieldset>
    <fieldset>
    <legend>Vaccinatie, is de hond gevaccineerd tegen</legend>
            <?php echo isset($aErrors['carre']) ? '<li class="error">' : '<li>' ?>
            <label for="carre" >carre<em>*</em></label>
            <input type="radio" name="carre" id="carreY" value="j"<?php echo ( isset($_POST['carre']) and $_POST['carre'] == 'j' ) ? ' checked="checked"' : '' ?> /> Ja
            <input type="radio" name="carre" id="carreN" value="n"<?php echo ( isset($_POST['carre']) and $_POST['carre'] == 'n' ) ? ' checked="checked"' : '' ?> /> Nee
            </li>
            <?php echo isset($aErrors['parvovirose']) ? '<li class="error">' : '<li>' ?>
            <label for="parvovirose" >Parvovirose<em>*</em></label>
            <input type="radio" name="parvovirose" id="parvoviroseY" value="j"<?php echo ( isset($_POST['parvovirose']) and $_POST['parvovirose'] == 'j' ) ? ' checked="checked"' : '' ?> /> Ja
            <input type="radio" name="parvovirose" id="parvoviroseN" value="n"<?php echo ( isset($_POST['parvovirose']) and $_POST['parvovirose'] == 'n' ) ? ' checked="checked"' : '' ?> /> Nee
            </li>
            <?php echo isset($aErrors['hepatitis']) ? '<li class="error">' : '<li>' ?>
            <label for="hepatitis" >Hepatitis contagiosa canis<em>*</em></label>
            <input type="radio" name="hepatitis" id="hepatitisY" value="j"<?php echo ( isset($_POST['hepatitis']) and $_POST['hepatitis'] == 'j' ) ? ' checked="checked"' : '' ?> /> Ja
            <input type="radio" name="hepatitis" id="hepatitisN" value="n"<?php echo ( isset($_POST['hepatitis']) and $_POST['hepatitis'] == 'n' ) ? ' checked="checked"' : '' ?> /> Nee
            </li>
            <?php echo isset($aErrors['kennelhoest']) ? '<li class="error">' : '<li>' ?>
            <label for="kennelhoest" >Kennelhoest<em>*</em></label>
            <input type="radio" name="kennelhoest" id="kennelhoestY" value="j"<?php echo ( isset($_POST['kennelhoest']) and $_POST['kennelhoest'] == 'j' ) ? ' checked="checked"' : '' ?> /> Ja
            <input type="radio" name="kennelhoest" id="kennelhoestN" value="n"<?php echo ( isset($_POST['kennelhoest']) and $_POST['kennelhoest'] == 'n' ) ? ' checked="checked"' : '' ?> /> Nee
            </li>
    </fieldset>
        <input type="submit" value="Verstuur" />
   </form>
<?php include_once('footer.php')?>