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Blue Cross


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IEHP


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Medicare


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Preferred One


Primecare of Corona (HMO)


United Health Care


        

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<% Dim sTo, sFrom, Subject, sMailServer, sBody, saved saved=0 if request("txtName") <> "" then savedata end if sub savedata on error resume next Dim strINS_Stmt Dim vartxtName, vartxtEmail, vartxtDayPh, vartxtEvePh, vartxtSubject, vartxtAppDate, vartxtAppTime, vartxtMessage, vartxtSource vartxtName = Trim(Request("txtName")) vartxtEmail = Trim(Request("txtEmail")) vartxtDayPh = Trim(Request("txtdayPh")) vartxtEvePh = Trim(Request("txtEvePh")) if vartxtDayPh = "xxx-xxx-xxxx" then vartxtDayPh="" end if vartxtEvePh = Trim(Request("txtEvePh")) if vartxtEvePh = "xxx-xxx-xxxx" then vartxtEvePh="" end if vartxtAppDate = Trim(Request("txtAppDate")) vartxtAppTime = Trim(Request("txtAppTime")) vartxtMessage = Trim(Request("txtMessage")) vartxtSource = Trim(Request("txtSource")) mes = "" IsSuccess = false sFrom = "ADMINISTRATION@QualityCarefp.com" sTo = "Appointments@Qualitycarefp.com" sSubject = "New Appointment Request" sMailServer = "mail-fwd" if vartxtDayPh = "" Then vartxtDayPh = "Not supplied" End If if vartxtEvePh = "" Then vartxtEvePh = "Not supplied" End If sBody = "Below are details for new Appointment" &_ "

Name : " & vartxtName & "

Email ID : " & vartxtEmail &_ "

Daytime Phone Number : " & vartxtdayPh & "

Evening Phone Number : " & vartxtEvePh &_ "

Source : " & vartxtSource &_ "

Preferred Appointment Date : " & vartxtAppDate &_ "

Preferred Appointment Time : " & vartxtAppTime &_ "

Message : " & vartxtMessage Set objMail = Server.CreateObject("CDO.Message") Set objConf = Server.CreateObject("CDO.Configuration") Set objFields = objConf.Fields With objFields .Item("http://schemas.microsoft.com/cdo/configuration/sendusing") = 2 .Item("http://schemas.microsoft.com/cdo/configuration/smtpserver") = sMailServer .Item("http://schemas.microsoft.com/cdo/configuration/smtpconnectiontimeout") = 10 .Item("http://schemas.microsoft.com/cdo/configuration/smtpserverport") = 25 .Update End With With objMail Set .Configuration = objConf .From = sFrom .To = sTo .CC = "Kat.holman@QualityCarefp.com" .Subject = sSubject .HTMLBody = sBody End With Err.Clear on error resume next objMail.Send Set objFields = Nothing Set objConf = Nothing Set objMail = Nothing sFrom = "ADMINISTRATION@QualityCarefp.com" sTo = vartxtEmail sSubject = "Your Appointment Request has been submitted" sMailServer = "mail-fwd" sBody = "Thank you for submitting your appointment request to the Quality Care Family Practice office staff. We will confirm your appointment via email OR will call you to suggest alternative date(s) and time(s). Please note that you can also call the Quality Care Family Practice office during regular office hours at (951) 808-3000 to schedule an appointment." &_ "

We look forward to seeing you soon." &_ "

Thank you," &_ "
Quality Care Family Practice Staff" Set objMail = Server.CreateObject("CDO.Message") Set objConf = Server.CreateObject("CDO.Configuration") Set objFields = objConf.Fields With objFields .Item("http://schemas.microsoft.com/cdo/configuration/sendusing") = 2 .Item("http://schemas.microsoft.com/cdo/configuration/smtpserver") = sMailServer .Item("http://schemas.microsoft.com/cdo/configuration/smtpconnectiontimeout") = 10 .Item("http://schemas.microsoft.com/cdo/configuration/smtpserverport") = 25 .Update End With With objMail Set .Configuration = objConf .From = sFrom .To = sTo .cc= "Kat.Holman@Qualitycarefp.com; Dr.Sathya@Qualitycarefp.com" .Subject = sSubject .HTMLBody = sBody End With Err.Clear on error resume next objMail.Send Set objFields = Nothing Set objConf = Nothing Set objMail = Nothing saved = 1 end sub %> <%if saved = 1 then %>

 Thank you for contacting Quality Care Family Practice.

 You will receive a confirmation email message shortly at the email address you provided.

<%else %>

Appointment Request

Your Name:
Your E-mail Address:
Daytime Phone Number:
Evening Phone Number:
Please select your preferred appointment date:
Please select your preferred appointment time:

Please note that it is likely that your preferred Date and/or Time may
not be available. We will email or call you to confirm your
appointment

Message:
How did you hear about us?:
<%end if%>


QUALITY CARE FAMILY PRACTICE
2083 Compton Ave,
Suite 105,
Corona, CA 92881
Phone: (951)808-3000
Fax: (951)403-6626
Office Hours:
MON-FRI: 9AM-5PM
SAT: By Appointment Only

After Hours:
On Call 24 Hours

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