<% Dim strTo, strSubject, strBody 'Strings for recipient, subject, body Dim objCDOMail 'The CDO object strTo = Request.Form("to") strSubject = Request.Form("subject") strBody = Request.Form("body") strBody = strBody & vbCrLf & vbCrLf strBody = strBody & "--" strBody = strBody & vbCrLf strBody = strBody & Request.Form("name") strBody = strBody & vbCrLf strBody = strBody & Request.Form("email") strBody = strBody & vbCrLf strBody = strBody & Request.Form("address") strBody = strBody & vbCrLf strBody = strBody & Request.Form("city") & ", " & Request.Form("state") & Request.Form("zip") strBody = strBody & vbCrLf strBody = strBody & Request.Form("phone_area") & "-" & Request.Form("phone_number") strBody = strBody & vbCrLf strBody = strBody & Request.Form("workphone_area") & "-" & Request.Form("workphone_number") & "ext" & Request.Form("workphone_ext") strBody = strBody & vbCrLf strBody = strBody & vbCrLf strBody = strBody & "- - - - - - - - - - - -" strBody = strBody & vbCrLf strBody = strBody & vbCrLf strBody = strBody & "PRESCRIPTION INFORMATION" strBody = strBody & "Prescription:" & Request.Form("prescription") strBody = strBody & vbCrLf strBody = strBody & "Strength:" & Request.Form("prescription_strength") strBody = strBody & vbCrLf strBody = strBody & "Dose:" & Request.Form("prescription_dose") strBody = strBody & vbCrLf strBody = strBody & "Quantity:" & Request.Form("prescription_quantity") strBody = strBody & vbCrLf strBody = strBody & "Last Pharmacy Filled At:" & Request.Form("prescription_lastpharmacy") strBody = strBody & vbCrLf strBody = strBody & "Refill Information:" & Request.Form("prescription_refill") strBody = strBody & vbCrLf strBody = strBody & "Fill at Pharmacy:" & Request.Form("prescription_pharmacy") strBody = strBody & vbCrLf strBody = strBody & "Second Choice:" & Request.Form("prescription_second") strBody = strBody & vbCrLf strBody = strBody & Request.Form("comments") strBody = strBody & vbCrLf strBody = strBody & vbCrLf If strTo = "" Or Not IsValidEmail(strTo) Then %> Prescriptions and refills for medications are usually issued during office hours only. On evenings and weekends it is difficult for the doctor on call for the practice to determine if a prescription or refill is indicated without your medical record before him. Therefore, our doctors do not routinely write prescriptions or issue refills after hours. If you have reason to believe that the medication is required, please furnish the prescription number and the telephone number of your pharmacy when you call.

Please Note: You must be a current COA patient to use this form.


NAME
DATE OF BIRTH
EMAIL
ADDRESS
CITY
STATE
ZIP
HOME PHONE - No dashes, please.
WORK PHONE - ext. No dashes, please.
Prescription:
Strength:
Dose:
Quantity:
Pharmacy Last Filled:
Call Refill Into Which Pharmacy:
Pharmacy Phone Number:
2nd Choice:
COMMENTS/ INSTRUCTIONS

Medical Assistance
Ultram:
Ortho Pharmaceuticals
Thomas Schwend, Mngr.
Medical Information
Ortho Pharmaceutical Corp.
P.O. Box 300
Route 202 South
Raritan, NJ 08869-0602
1-800-797-7737		 McNeil Pharmaceuticals
Thomas Schwend, Mngr.
Medical Information
Ortho Pharmaceutical Corp.
P.O. Box 300
Route 202 South
Raritan, NJ 08869-0602
1-800-797-7737
VIOXX
Merck Co., Inc.
Patient Assistance Program
P.O. Box 4-WP35-258
West Point, PA 19486-0004
215-652-5000 (collect calls)		 The Medicine Program
P.O. Box 520
Doniphan, MO 63935-0520
(573) 996-7300
Searle Patients-In-Need Foundation
M5200 Old Orchard Rd.
Skokie, IL 6077
1-800-542-2526 		Celebrex (Searle)
Patient's-In-Need
P.O. Box 52059
Phoenix, AZ 85072
1-800-542-2526
Reimbursement - Celebrex/Arthotec
 The Searle Patient Promise
P.O. Box 92110
Elk Grove Village, IL 60009-2110








<% Else Set objCDOMail = Server.CreateObject("CDONTS.NewMail") objCDOMail.From = "COA Refills " objCDOMail.To = strTo objCDOMail.Cc = StrEmail objCDOMail.Subject = strSubject objCDOMail.Body = strBody ' Some of the more useful ones I've included samples of here: 'objCDOMail.Cc = "user@domain.com;user@domain.com" 'objCDOMail.Bcc = "user@domain.com;user@domain.com" 'objCDOMail.Importance = 1 '(0=Low, 1=Normal, 2=High) 'objCDOMail.AttachFile "c:\path\filename.txt", "filename.txt" ' I've had several requests for how to send HTML email. ' To do so simply set the body format to HTML and then ' compose your body using standard HTML tags. 'objCDOMail.BodyFormat = 0 ' CdoBodyFormatHTML 'Outlook gives you grief unless you also set: 'objCDOMail.MailFormat = 0 ' CdoMailFormatMime ' Send the message! objCDOMail.Send ' Set the object to nothing because it immediately becomes ' invalid after calling the Send method. Set objCDOMail = Nothing Response.Write "




Your prescription has been successfully submitted!



" End If ' End page logic %> <% ' Only functions and subs follow! ' A quick email syntax checker. It's not perfect, ' but it's quick and easy and will catch most of ' the bad addresses than people type in. Function IsValidEmail(strEmail) Dim bIsValid bIsValid = True If Len(strEmail) < 5 Then bIsValid = False Else If Instr(1, strEmail, " ") <> 0 Then bIsValid = False Else If InStr(1, strEmail, "@", 1) < 2 Then bIsValid = False Else If InStrRev(strEmail, ".") < InStr(1, strEmail, "@", 1) + 2 Then bIsValid = False End If End If End If End If IsValidEmail = bIsValid End Function %>