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Apr 23rd, 2018
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  1. <div class="form-group">
  2. <p>Have you worn contact Lens before?</p>
  3. <input type="radio" name="lenses" value="Yes"/> Yes<br>
  4. <input type="radio" name="lenses" value="No"/> No<br>
  5. </div>
  6. <div class="form-group">
  7. <p>If yes, which type of disposable contact lens have you worn before?</p>
  8. <input type="checkbox" name="disposable_lens[]" value="Monthly"/> Monthly<br>
  9. <input type="checkbox" name="disposable_lens[]" value="Daily Disposables"/> Daily Disposables<br>
  10. </div>
  11.  
  12. if(isset($_POST["submit"]))
  13. {
  14. if(empty($_POST["lenses"]))
  15. {
  16. $error .= '<p><label class="text-danger">Lenses is required</label></p>';
  17. }
  18. else
  19. {
  20. $lenses = clean_text($_POST["lenses"]);
  21. }
  22. if(empty($_POST["disposable_lens"]))
  23. {
  24. $error .= '<p><label class="text-danger">Disposable_lens is required</label></p>';
  25. }
  26. else
  27. {
  28. $disposable_lens = array_map('clean_text', $_POST["disposable_lens"]);
  29.  
  30. $mail->Body = join('', array(
  31. "Outlet: ",
  32. $_POST['outlet'],
  33. "<br/>",
  34. "Full Name: ",
  35. $_POST['fullname'],
  36. "<br/>",
  37. "Email Address: ",
  38. $_POST['email'],
  39. "<br/>",
  40. "Phone Number:",
  41. $_POST['contact_no'],
  42. "<br/>",
  43. "Have you worn contact lens before?: ",
  44. $_POST['lenses'],
  45. "<br/>",
  46. "If yes, which type of disposable contact lens have you worn before?: ",
  47. join(', ', $_POST['disposable_lens']),
  48. "<br/>",
  49. "Appointment Date ",
  50. $_POST['date'],
  51. "<br/>",
  52. "Appointment Time ",
  53. $_POST['time']
  54. ));
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