$v){ foreach($badStrings as $v2){ if(strpos($v, $v2) !== false){ header("HTTP/1.0 403 Forbidden"); exit; } } } unset($k, $v, $v2, $badStrings, $authHosts, $fromArray, $wwwUsed); $my_form = new validator; if ($my_form->validate_fields('name, email')) { // Required Fields $display = '
'; $mail = new PHPMailer(); $mail->IsHTML(true); // Add Attachment $mail->AddAttachment($_FILES['attached_file']['tmp_name'],$_FILES['attached_file']['name']); // Add Attachment 2 $mail->AddAttachment($_FILES['attached_file2']['tmp_name'],$_FILES['attached_file2']['name']); // Add Attachment 3 $mail->AddAttachment($_FILES['attached_file3']['tmp_name'],$_FILES['attached_file3']['name']); $mail->From = $_POST['email']; // The email field $mail->FromName = $_POST['name']; // The name field $mail->AddAddress('emailaddresshere'); // the form will be sent to this address $mail->AddAddress($_POST['email'],$_POST['name']); // form email field, form name field so we can send a copy to the form sender $mail->Subject = 'Evaluation Form'; // the subject of email // html text block $mail->Body .= 'First Name:' . $_POST['name'] . '
' . "\n"; $mail->Body .= 'Last Name:' . $_POST['lname'] . '
' . "\n"; $mail->Body .= 'Sex:' . $_POST['sex1'] . $_POST['sex2'] . '
' . "\n"; $mail->Body .= 'DOB:' . $_POST['dob'] . '
' . "\n"; $mail->Body .= 'Email:' . $_POST['email'] . '
' . "\n"; $mail->Body .= 'Phone:' . $_POST['phone'] . '
' . "\n"; $mail->Body .= 'Address:' . $_POST['address'] . '
' . "\n"; $mail->Body .= 'Preferred Method of Contact:' . $_POST['email1'] . $_POST['phone1'] . '
' . "\n"; $mail->Body .= 'Current Level of Hair Loss:' . $_POST['level1'] . $_POST['level2'] . $_POST['level3'] . $_POST['level4'] . $_POST['level5'] . $_POST['level6'] . $_POST['level7'] . $_POST['level8'] . $_POST['level9'] . '
' . "\n"; $mail->Body .= 'Family History of Hair Loss:' . $_POST['history1'] . $_POST['history2'] . '
' . "\n"; $mail->Body .= 'Currently Using Any Medications:' . $_POST['med1'] . $_POST['med2'] . $_POST['med3'] . $_POST['med4'] . '
' . "\n"; $mail->Body .= 'Have You Ever Had Hair Transplant Before? :' . $_POST['transp1'] .$_POST['transp2'] . '
' . "\n"; $mail->Body .= 'If so, how many grafts:' . $_POST['grafts'] . '
' . "\n"; $mail->Body .= 'Like to Achieve:' . $_POST['achieve'] . '
' . "\n"; $mail->Body .= 'Hair Texture:' . $_POST['texture1'] . $_POST['texture2'] . $_POST['texture3'] . '
' . "\n"; $mail->Body .= 'How Did You Hear About Us:' . $_POST['hear1'] . $_POST['hear2'] . $_POST['hear3'] . $_POST['hear4'] . $_POST['hear5'] . $_POST['hear6'] . '
' . "\n"; $mail->Body .= '' . "\n"; // plain text block $mail->AltBody .= 'First Name:' . $_POST['name'] . "\n"; $mail->AltBody .= 'Last Name:' . $_POST['lname'] . "\n"; $mail->AltBody .= 'Sex:' . $_POST['sex1'] . $_POST['sex2'] . "\n"; $mail->AltBody .= 'DOB:' . $_POST['dob'] . "\n"; $mail->AltBody .= 'Email:' . $_POST['email'] . "\n"; $mail->AltBody .= 'Phone:' . $_POST['phone'] . "\n"; $mail->AltBody .= 'Address:' . $_POST['address'] . "\n"; $mail->AltBody .= 'Preferred Method of Contact:' . $_POST['email1'] . $_POST['phone1'] . "\n"; $mail->AltBody .= 'Current Level of Hair Loss:' . $_POST['level1'] . $_POST['level2'] . $_POST['level3'] . $_POST['level4'] . $_POST['level5'] . $_POST['level6'] . $_POST['level7'] . $_POST['level8'] . $_POST['level9'] . "\n"; $mail->AltBody .= 'Family History of Hair Loss:' . $_POST['history1'] . $_POST['history2'] . "\n"; $mail->AltBody .= 'Currently Using Any Medications:' . $_POST['med1'] . $_POST['med2'] . $_POST['med3'] . $_POST['med4'] . "\n"; $mail->AltBody .= 'Have You Ever Had Hair Transplant Before? :' . $_POST['transp1'] .$_POST['transp2'] . "\n"; $mail->AltBody .= 'If so, how many grafts:' . $_POST['grafts'] . "\n"; $mail->AltBody .= 'Like to Achieve:' . $_POST['achieve'] . "\n"; $mail->AltBody .= 'Hair Texture:' . $_POST['texture1'] . $_POST['texture2'] . $_POST['texture3'] . "\n"; $mail->AltBody .= 'How Did You Hear About Us:' . $_POST['hear1'] . $_POST['hear2'] . $_POST['hear3'] . $_POST['hear4'] . $_POST['hear5'] . $_POST['hear6'] . "\n"; $mail->Send(); } else { $display = '
'; } } ?>

First Name:*
Last Name:
Sex:	Male Female
DOB:
E-Mail:*
Phone:
Address:
Preferred method of Contact:	E-Mail Phone
Current level of hair loss?
Family history of hair loss?	Yes No
Are you currently using any medications or products to treat your hair loss?	Propecia Minoxidil Other:
Have you ever had a hair transplant before?	Yes No
If so, how many grafts?
What would you like to achieve with hair restoration?
Describe your hair texture:	Thin Medium Coarse
How did you hear about us?	A Friend/Patient Search Engine Hair Forums Newspaper Internet Television
Photo Guidelines: 1. Use natural lighting and avoid flash 2. Photos should be taken from a distance of at least 3 feet Attach Image: Attach Image: Attach Image: Please attach photos in one of the following file formats: .jpg, .png, .gif, .tif - (10 MB Sending Limit)