Formatting Email from HTML Form

[jcarmody]

I am really a novice at HTML code. I have been able to follow examples to set up an HTML form that allows the user to fill out the form and attach a file. The form contents and attachment send an email. All works great. However the person processing the request now tells me that they need to have the email formatted so it looks like the webpage itself. Apparently they want to scan the request and archive it.

I have searched high and low and can't seem to get my hands on a solution that I can comprehend. Any ideas would be appreciated.

JC

 

[vacunita]

Well basically you need to construct an HTML email.

Now since we don't know how you are building and sending the email its hard to suggest anything.




----------------------------------
Phil AKA Vacunita
----------------------------------
Ignorance is not necessarily Bliss, case in point:
Unknown has caused an Unknown Error on Unknown and must be shutdown to prevent damage to Unknown.

 

[jcarmody]

I am embarassed to supply the code - since its so messy. But here it is.

<%



NavigationSection = "Member"
NavigationSubsection = "Forms"
PageTitle = "GH Benefits"
PageSubtitle = ""
MetaDescription = ""
MetaKeywords = ""
Const systemMailServer = "xxx.xxx.x.xx"
Const systemMailServerPort = 25
'--------------------------------------------------------------------------------'
Function URLDecodeHex(Match, HexDigits, Position, Source)
URLDecodeHex = Chr("&H" & HexDigits)
End Function
'--------------------------------------------------------------------------------'
Function URLDecode(InputString)
Set RegEx = new RegExp
OutputString = Replace(InputString, "+", " ")
RegEx.Global = True
RegEx.Pattern = "%([0-9a-fA-F]{2})"
URLDecode = RegEx.Replace(OutputString, GetRef("URLDecodeHex"))
Set RegEx = Nothing
End Function
'--------------------------------------------------------------------------------'
Function CheckForErrors()
If Err.Number <> 0 Then
Response.Redirect(MailRedirectError)
Response.End()
End If

End Function
'--------------------------------------------------------------------------------'
'--------------------------------------------------------------------------------'
Function RenderString(FieldName)
If DataCollectionString.Exists(FieldName) Then
FieldValue = DataCollectionString(FieldName)
FieldValue = Replace(FieldValue, "<", "<")
FieldValue = Replace(FieldValue, ">", ">")
FieldValue = Replace(FieldValue, """", """)
RenderString = FieldValue
Else
RenderString = ""
End If
End Function
'--------------------------------------------------------------------------------'
'--------------------------------------------------------------------------------'
Function RenderCurrency(FieldName)
If DataCollectionNumeric.Exists(FieldName) Then
FieldValue = DataCollectionNumeric(FieldName)
If IsNumeric(FieldValue) Then FieldValue = CCur(FieldValue)
If FieldValue > 0 Then RenderCurrency = FormatCurrency(FieldValue, 2) Else RenderCurrency = ""
Else
RenderCurrency = ""
End If
End Function
'--------------------------------------------------------------------------------'

On Error Resume Next

Set FileUpload = Server.CreateObject("ABCUpload4.XForm")
With FileUpload
.Overwrite = True
.AbsolutePath = True
.MaxUploadSize = 10240000
End With


MailFrom = Trim(FileUpload.Form("MailFrom"))
MailTo = Trim(FileUpload.Form("MailTo"))
MailSubject = Trim(FileUpload.Form("MailSubject"))
MailRedirect = Trim(FileUpload.Form("MailRedirect"))
MailRedirectError = Trim(FileUpload.Form("MailRedirectError"))
CheckForErrors()

For Each FieldItem In FileUpload
FieldForm = FieldForm & Server.URLEncode(FieldItem) & "="
FormValues = ""
For Each FieldValue In FileUpload(FieldItem)
If Len(FieldValue.FileType) > 0 Then
FormValues = Server.URLEncode("Attachment (""" & FieldValue.SafeFileName & """)") & ","
Else
FormValues = FormValues & Server.URLEncode(FieldValue) & ","
End If
Next
If Len(FormValues) > 0 Then FormValues = Left(FormValues, Len(FormValues) - 1)
FieldForm = FieldForm & FormValues & "&"
Next
If Len(FieldForm) > 0 Then FieldForm = Left(FieldForm, Len(FieldForm) - 1)
CheckForErrors()

If InStr(FieldForm, "&") Then
ParameterValuePairs = Split(FieldForm, "&")

For Counter = 0 To UBound(ParameterValuePairs)
Parts = Split(ParameterValuePairs(Counter), "=")
CurrentParameter = Trim(URLDecode(Parts(0)))

Select Case LCase(CurrentParameter)
Case "mailfrom", "mailto", "mailsubject", "mailredirect", "mailredirecterror", "x", "y"
Case Else
CurrentValue = URLDecode(Parts(1))
MailMessage = MailMessage & CurrentParameter & ": " & CurrentValue & vbCrLf
End Select
Next
Else
MailMessage = ""
End If
CheckForErrors()

TempPath = Server.MapPath("/resource/temp/")

Set CDOMessage = Server.CreateObject("CDO.Message")
Set FSO = Server.CreateObject("Scripting.FileSystemObject")

CDOMessage.From = MailFrom
CDOMessage.To = MailTo
CDOMessage.Subject = MailSubject
CDOMessage.TextBody = MailMessage
CheckForErrors()

With CDOMessage.Configuration.Fields
' 1 - Send messages through local SMTP service
' 2 - Send messages through network SMTP service
.Item("

http://schemas.microsoft.com/cdo/configuration/sendusing")

= 2 ' cdoSendUsingPort
.Item("

http://schemas.microsoft.com/cdo/configuration/smtpserver")

= systemMailServer
.Item("

http://schemas.microsoft.com/cdo/configuration/smtpserverport")

= systemMailServerPort

.Update()
End With
CheckForErrors()

For Each FileData in FileUpload.Files
If FileData.FileExists Then
Select Case LCase(FileData.FileType)
Case "jpg", "jpeg", "gif", "bmp", "pdf","png"
FilePath = TempPath & "\" & FileData.SafeFileName
FileData.Save(FilePath)
CDOMessage.AddAttachment(FilePath)
End Select
End If
CheckForErrors()
Next

If Not IsError Then
CDOMessage.Send()
End If
For Each FileData in FileUpload.Files
If FileData.FileExists Then
Select Case LCase(FileData.FileType)
Case "jpg", "jpeg", "gif", "bmp", "png"
FilePath = TempPath & "\" & FileData.SafeFileName
FSO.DeleteFile(FilePath)
End Select
End If
Next

Set FSO = Nothing
Set CDOMessage = Nothing

Set FileUpload = Nothing

CheckForErrors()

Response.Redirect(MailRedirect)

%>


<!--#include virtual="/include/common.asp"-->
<!--#include virtual="/app/member/navigation/index.asp"-->
<%

'-- APPLICATION Permissions -----------------------------------------------------'
If CheckPermission("appCONTACT", "R") = False Then
RaiseMessage("14842")
MessageRedirect("/app/overview/")
End If
'--------------------------------------------------------------------------------'



DBQuery = "SELECT Users.ID AS UserID, [Full Address].Addr1 AS Addr1, [Full Address].Addr2 AS Addr2, " & _
" [Full Address].City As City, [Full Address].State AS State, [Full Address].Zip As Zip, [Full Address].MemberNumber AS MemberNumber, " & _
" Users.EmailAddress As Email, Users.PhoneNumber as Phone, Users.FaxNumber as Fax, Users.Username, Users.Name As Name " & _
" FROM [Full Address] INNER JOIN Users ON [Full Address].MemberNumber = Users.MemberNumber " & _
" WHERE Users.ID = " & Session("UserID")


Set DBCon = Server.CreateObject("ADODB.Connection")
DBCon.Open Application("DB")
Set DBRec = Server.CreateObject("ADODB.Recordset")
DBRec.Open DBQuery, DBCon, 1, 1
If DBRec.EOF and DBRec.BOF then
RaiseMessage("14877")
Else
FieldMemberNumber = DBRec("MemberNumber")
FieldName = DBRec("Name")
FieldAddr1 = DBRec("Addr1")
FieldAddr2 = DBRec("Addr2")
FieldCity = DBRec("City")
FieldState = DBRec("State")
FieldZip = DBRec("Zip")
FieldPhoneNumber = DBREC("Phone")
FieldFaxNumber = DBREC("Fax")
FieldEmailAddress = DBRec("Email")
FieldForm = "GH Benefits"
FieldEdate = Now()
End If
DBRec.Close
Set DBRec = Nothing
DBCon.Close
Set DBCon = Nothing

SelectedItemID = CLng(CNumeric(Request.QueryString("ID")))
If SelectedItemID = 0 Then SelectedItemID = CLng(CNumeric(Request.Form("ID")))

IsPostBack = CLng(CNumeric(Request.Form("PostBack")))
If IsPostBack = 1 Then IsPostBack = True Else IsPostBack = False

CurrentDate = Now()

If IsPostBack Then
SubmissionValid = True


FieldMemberNumber = Trim(Request.Form("MemberNumber"))
FieldName = Trim(Request.Form("Name"))
FieldEmailAddress = Trim(Request.Form("Email"))
FieldAddr1 = Trim(Request.Form("Addr1"))
FieldAddr2 = Trim(Request.Form("Addr2"))
FieldCity = Trim(Request.Form("City"))
FieldState = Trim(Request.Form("State"))
FieldZip = Trim(Request.Form("Zip"))
FieldPhoneNumber = ScrubSQLString(Trim(Request.Form("Phone")), 25)
FieldInitials = Trim(Request.Form("Initials"))
FieldEdate = Trim(Request.Form("EDate"))

end if


%>
<!--#include virtual="/include/header.asp"-->
<script language="JavaScript">
<!--//
var resetFieldColor;
function sFC(region) { resetFieldColor = region.parentNode.parentNode.bgColor; region.parentNode.parentNode.bgColor = '#FDF8C3'; }
function rFC(region) { region.parentNode.parentNode.bgColor = resetFieldColor; }

function filterNumeric(e) {
if(window.event) var keyCode = e.keyCode;// IE
else if (e.which) var keyCode = e.which; // Netscape/Firefox/Opera

var found = false;
if (keyCode >= 48 && keyCode <= 57) found = true;
if (keyCode >= 96 && keyCode <= 105) found = true;

switch (keyCode) {
case 190: // . (Standard Keypad)
case 189: // - (Standard Keypad)
case 110: // . (Numeric Keypad)
case 109: // - (Numeric Keypad)
case 188: // ,
case 36: // $
case 8: // Backspace
case 46: // Delete
case 37: // Left Arrow
case 39: // Right Arrow
case 16: // Shift
case 27: // Escape
case 9: // Tab
found = true;
break;
}

return found;
}

function fC(element) {
if (element.value.length > 0) element.value = formatCurrency(element.value);
calculateForm();
}

function formatCurrency(num) {
num = num.toString().replace(/\$|\,/g,'');
if(isNaN(num)) num = '0';
sign = (num == (num = Math.abs(num)));
num = Math.floor(num * 100 + 0.50000000001);
cents = num % 100;
num = Math.floor(num / 100).toString();
if(cents < 10) cents = '0' + cents;
for (var i = 0; i < Math.floor((num.length - (1 + i)) / 3); i++) num = num.substring(0, num.length - (4 * i + 3)) + ',' + num.substring(num.length - (4 * i + 3));
return (((sign) ? '' : '-') + '$' + num + '.' + cents);
}
function mirrorField(sourceField, destinationField) {
sourceField = getObjectById(sourceField);
destinationField = getObjectById(destinationField);
if (destinationField.value != sourceField.value) destinationField.value = sourceField.value;
}

function sumFields(sourceFields) {
var sourceFields = sourceFields.split('|');
var totalValue = 0;

for (var counter = 0; counter < sourceFields.length; counter++) {
sourceField = getObjectById(sourceFields[counter]);
sourceFieldValue = parseFloat(sourceField.value.replace(',', '').replace('$', ''));
if (isNaN(sourceFieldValue)) sourceFieldValue = 0;
totalValue += sourceFieldValue;
}

return totalValue;
}

function getFieldValue(Field) {
Field = getObjectById(Field);
FieldValue = parseFloat(Field.value.replace(',', '').replace('$', ''));
if (isNaN(FieldValue)) FieldValue = 0;
return FieldValue;
}

function calculateForm() {


getObjectById('AmtPaid1').value = formatCurrency(getFieldValue('TotalExpense1') - getFieldValue('Insurance Paid Amount1'));
getObjectById('AmtPaid2').value = formatCurrency(getFieldValue('TotalExpense2') - getFieldValue('Insurance Paid Amount2'));
getObjectById('AmtPaid3').value = formatCurrency(getFieldValue('TotalExpense3') - getFieldValue('Insurance Paid Amount3'));
getObjectById('AmtPaid4').value = formatCurrency(getFieldValue('TotalExpense4') - getFieldValue('Insurance Paid Amount4'));
}

//-->
</script>

<script language="JavaScript">
<!--//
function validate_required(field,alerttxt)
{
with (field)
{
if (value==null||value=="")
{
alert(alerttxt);return false;
}
else
{
return true;
}
}
}

function validate_form(thisform)
{
with (thisform)
{

if (validate_required(Initials,"Initials are required")==false)
{Initials.focus();return false;}

if (validate_required(ServiceDate1,"Date is required")==false)
{ServiceDate1.focus();return false;}

if (validate_required(location1,"Location is required")==false)
{location1.focus();return false;}

if (validate_required(TotalExpense1,"Total Expense is required")==false)
{TotalExpense1.focus();return false;}


if (validate_required(Proof,"Valid receipt is required")==false)
{Proof.focus();return false;}

}

}


//-->
</script>

<form name="frmMain" method="post" onsubmit="return validate_form(this)" action="index.asp" enctype="multipart/form-data">
<input type="hidden" name="MailFrom" value=xxx@xxx.com">
<input type="hidden" name="MailTo" value="xxx@wxxx.com">
<input type="hidden" name="MailSubject" value="GH Benefit Request">
<input type="hidden" name="MailRedirect" value="thanks.asp">
<input type="hidden" name="MailRedirectError" value="error.asp">
<input type="hidden" name="DateTime" value="<%= Now() %>">
<input type="hidden" name="UserID" value="<%= FieldEmailAddress %>">
<input type="hidden" name="Referrer" value="<%= Request.ServerVariables("HTTP_REFERER") %>">



<table cellpadding="3" cellspacing="0" border="0" style="width:100%; table-layout:fixed;">
<colgroup>
<col style="width:75%;" />
<col style="width:25%;" />
</colgroup>

<Tr>
<td>Please complete the following. The claim cannot be processed without the completed Application and proof of out-of-pocket expense. </td>

<td></td>
<tr><td colspan="2"><hr size="1" style="color:#EEEEEE; background-color:#EEEEEE; height:1px; border:none; margin:0; padding:0;"></td></tr>
</Tr>
</table>

<table cellpadding="3" cellspacing="0" border="0" style="width:100%; table-layout:fixed;">
<colgroup>
<col style="width:25%;" />
<col style="width:75%;" />
</colgroup>
<tr>
<td>Entry Date / Time</td>
<td><input type="text" name="Entry Date" value="<%= FieldEDate %>" readonly="readonly" style="width:37%" maxlength="25" class="TextBox<%= FieldEDateClass %>" /></td>
</tr>
<tr>
<td></td>
<td><input type="Hidden" name="Form" value="<%= Fieldform %>" readonly="readonly" style="width:17%" maxlength="25" class="TextBox<%= Fieldform %>" /></td>
</tr>
<tr>
<td>Member Number</td>
<td><input type="text" name="Member Number" value="<%= FieldMemberNumber %>" readonly="readonly" style="width:37%" maxlength="25" class="TextBox<%= FieldMemberNumberClass %>" /></td>
</tr>

<tr>
<td>Name</td>
<td><input type="text" name="Name" value="<%= FieldName %>" readonly="readonly" style="width:37%" maxlength="37" class="TextBox<%= FieldNameClass %>" /></td>
</tr>

<tr><td colspan="2"><hr size="1" style="color:#EEEEEE; background-color:#EEEEEE; height:1px; border:none; margin:0; padding:0;"></td></tr>


<tr>
<td>Apartment / Suite </td>
<td><input type="text" name="Addr1" value="<%= FieldAddr1 %>" maxlength="25" style="width:37%" class="TextBox<%= FieldAddr1Class %>" /></td>
</tr>
<tr>
<td>Street Address</td>
<td><input type="text" name="Addr2" value="<%= FieldAddr2 %>" maxlength="25" style="width:37%" class="TextBox<%= FieldAddr2Class %>" /></td>
</tr>

<tr>
<td>City</td>
<td><input type="text" name="City" value="<%= FieldCity %>" maxlength="25" style="width:37%" class="TextBox<%= FieldCityClass %>" /></td>
</tr>

<tr>
<td>State</td>
<td><input type="text" name="State" value="<%= FieldState %>" size="2" maxlength="2" style="width:8%" class="TextBox<%= FieldStateClass %>" /></td>
</tr>

<tr>

<td>Zip Code</td>
<td><input type="text" name="Zip" value="<%= FieldZip %>" maxlength="10" style="width:15%" class="TextBox<%= FieldZipClass %>" /></td>

</tr>


<tr>
<td>Phone Number</td>
<td>
<%= FieldPhoneNumberError %><input type="text" name="Phone Number" value="<%= FieldPhoneNumber %>" style="width:31%" maxlength="20" class="TextBox Short<%= FieldPhoneNumberClass %>" />
<span style="color:#999999; font-size:80%;">Format: (###) ###-####</span>
</td>
</tr>
<tr>
<td>Fax Number</td>
<td>
<%= FieldfaxNumberError %><input type="text" name="Fax Number" value="<%= FieldfaxNumber %>" style="width:31%" maxlength="20" class="TextBox Short<%= FieldfaxClass %>" />
<span style="color:#999999; font-size:80%;">Format: (###) ###-####</span>
</td>
</tr>
<tr>
<td>Applying for:</td>
<td>
<input type="radio" name="Benefit" value="Breast Cancer Screening Benefit" /> Breast Cancer Screening Benefit
<br />
<input type="radio" name="Benefit" value="Colon Cancer Screening" /> Colon Cancer Screening Benefit
<br />
<input type="radio" name="Benefit" value="Annual Physicial Good Health" /> Annual Physical Good Health Benefit
</tr>

<br>
<br>


<table cellpadding="3" cellspacing="0" border="1" style="width:100%; table-layout:fixed;">
<colgroup>
<col width="7%">
<col width="20%">
<col width="7%">
<col width="7%">
<col width="7%">
</colgroup>
<tr>
<td align="center">Date of Service</td>
<td align="center">Name and Location of Physician, Hospital or Clinic</td>
<td align="center">Total Expense</td>
<td align="center">Amount Paid by Insurance</td>
<td align="center">Amount of Out-of-Pocket Expense</td>
</tr>
<tr>

<td>
<input type="Date" name="ServiceDate1" value="<%= FieldServiceDate1 %>" style="width:100%" maxlength="15" class="TextBox Short<%= FieldServiceDate1 %>" />
<span style="color:#999999; font-size:80%;"></span>
</td>
<td>
<input type="text" name="location1" value="<%= Fieldlocation1 %>" style="width:100%" maxlength="400" class="TextBox Short<%= Fieldlocation1 %>" />
<span style="color:#999999; font-size:80%;"></span>
</td>
<td>
<input type="text" name="TotalExpense1" value="<%= RenderCurrency("FieldTotalExpense1") %>" style="width:100%" maxlength="40" onKeyUp="calculateForm();" class="TextBox Short<%= FieldTotalExpense1 %>" />
<span style="color:#999999; font-size:80%;"></span>
</td>
<td>
<input type="text" name="Insurance Paid Amount1" value="<%= RenderCurrency("Fieldinsamt1") %>" style="width:100%" maxlength="40" onKeyUp="calculateForm();" class="TextBox Short<%= Fieldinsamt1 %>" />
<span style="color:#999999; font-size:80%;"></span>
</td>
<td>
<input type="text" name="AmtPaid1" value="<%= FieldAmtPaid1 %>" style="width:100%" maxlength="40" onKeyUp="calculateForm();" readonly="readonly" class="TextBox Short<%= FieldAmtPaid1 %>" />
<span style="color:#999999; font-size:80%;"></span>
</td>

</tr>
<tr>

<td>
<input type="Date" name="ServiceDate2" value="<%= FieldServiceDate2 %>" style="width:100%" maxlength="40" class="TextBox Short<%= FieldServiceDate2 %>" />
<span style="color:#999999; font-size:80%;"></span>
</td>
<td>
<input type="text" name="location2" value="<%= Fieldlocation2 %>" style="width:100%" maxlength="400" class="TextBox Short<%= Fieldlocation2 %>" />
<span style="color:#999999; font-size:80%;"></span>
</td>
<td>
<input type="text" name="totalexpense2" value="<%= RenderCurrency("Fieldtotalexpense2") %>" style="width:100%" maxlength="40" onKeyUp="calculateForm();" class="TextBox Short<%= Fieldtotalexpense2 %>" />
<span style="color:#999999; font-size:80%;"></span>
</td>
<td>
<input type="text" name="Insurance Paid Amount2" value="<%= RenderCurrency("Fieldinsamt2") %>" style="width:100%" maxlength="40" onKeyUp="calculateForm();" class="TextBox Short<%= Fieldinsamt2 %>" />
<span style="color:#999999; font-size:80%;"></span>
</td>
<td>
<input type="text" name="AmtPaid2" value="<%= RenderCurrency("Fieldamtpd2") %>" style="width:100%" maxlength="40" onKeyUp="calculateForm();" readonly="readonly" class="TextBox Short<%= Fieldamtpd2 %>" />
<span style="color:#999999; font-size:80%;"></span>
</td>

</tr>
<tr>
<td>
<input type="Date" name="ServiceDate3" value="<%= FieldServiceDate3 %>" style="width:100%" maxlength="40" class="TextBox Short<%= FieldServiceDate3 %>" />
<span style="color:#999999; font-size:80%;"></span>
</td>
<td>
<input type="text" name="location3" value="<%= Fieldlocation3 %>" style="width:100%" maxlength="400" class="TextBox Short<%= Fieldlocation3 %>" />
<span style="color:#999999; font-size:80%;"></span>
</td>
<td>
<input type="text" name="totalexpense3" value="<%= RenderCurrency("Fieldtotalexpense3") %>" style="width:100%" maxlength="40" onKeyUp="calculateForm();" class="TextBox Short<%= Fieldtotalexpense3 %>" />
<span style="color:#999999; font-size:80%;"></span>
</td>
<td>
<input type="text" name="Insurance Paid Amount3" value="<%= RenderCurrency("Fieldinsamt3") %>" style="width:100%" maxlength="40" onKeyUp="calculateForm();" class="TextBox Short<%= Fieldinsamt3 %>" />
<span style="color:#999999; font-size:80%;"></span>
</td>
<td>
<input type="text" name="AmtPaid3" value="<%= RenderCurrency("Fieldamtpd3") %>" style="width:100%" maxlength="40" onKeyUp="calculateForm();" readonly="readonly" class="TextBox Short<%= Fieldamtpd3 %>" />
<span style="color:#999999; font-size:80%;"></span>
</td>

</tr>
<tr>
<td>
<input type="Date" name="ServiceDate4" value="<%= FieldServiceDate4 %>" style="width:100%" maxlength="40" class="TextBox Short<%= FieldServiceDate4 %>" />
<span style="color:#999999; font-size:80%;"></span>
</td>
<td>
<input type="text" name="location4" value="<%= Fieldlocation4 %>" style="width:100%" maxlength="400" class="TextBox Short<%= Fieldlocation4 %>" />
<span style="color:#999999; font-size:80%;"></span>
</td>
<td>
<input type="text" name="totalexpense4" value="<%= RenderCurrency("Fieldtotalexpense4") %>" style="width:100%" maxlength="40" onKeyUp="calculateForm();" class="TextBox Short<%= Fieldtotalexpense4 %>" />
<span style="color:#999999; font-size:80%;"></span>
</td>
<td>
<input type="text" name="Insurance Paid Amount4" value="<%= RenderCurrency("Fieldinsamt4") %>" style="width:100%" maxlength="40" onKeyUp="calculateForm();" class="TextBox Short<%= Fieldinsamt4 %>" />
<span style="color:#999999; font-size:80%;"></span>
</td>
<td>
<input type="text" name="AmtPaid4" value="<%= RenderCurrency("Fieldamtpd4") %>" style="width:100%" maxlength="40" onKeyUp="calculateForm();" readonly="readonly" class="TextBox Short<%= Fieldamtpd4 %>" />
<span style="color:#999999; font-size:80%;"></span>
</td>

</tr>
</table>
<br>

<table cellpadding="3" cellspacing="0" border="0" style="width:100%; table-layout:fixed;">
<colgroup>
<col style="width:25%;" />
<col style="width:75%;" />
</colgroup>

<tr>
<td align="left">List all Insurers (Including Medicaid/Medicare)</td>
<td>
<input type="text" name="Insurer" value="<%= FieldInsurer %>" style="width:100%" maxlength="400" class="TextBox Short<%= FieldInsurer %>" /></tr>
<tr>
<td align="left">Do you expect any further benefits to be paid on the above by your health insurance or other agency?</td>

</tr>
<tr>


<span style="color:#999999; font-size:80%;"></span>
</td>
<td>
<input type="radio" name="FurtherBenefit" value="Yes" /> Yes
<br />
<input type="radio" name="FurtherBenefit" value="No" /> No
<br />
</table>



<table width="100%" cellpadding="1" cellspacing="1" border="0">

<tr>
<td>Browse and attach Proof of out-of-pocket expense </td></tr>
<tr>
<td><input type="file" name="Proof" class="TextBox" /></td>
</tr>

<td> </td></tr>

<tr><td colspan="5"><hr size="1" style="color:#EEEEEE; background-color:#EEEEEE; height:1px; border:none; margin:0; padding:0;"></td></tr>

</tr>


<tr><td colspan="5"><hr size="1" style="color:#EEEEEE; background-color:#EEEEEE; height:1px; border:none; margin:0; padding:0;"></td></tr>

</tr>
</table>
<Table CellPadding = "3" Cellspacing="0" Border="0" stype="width:100%; table-layout:fixed;:>
<tr>
<td colspan="1">Initials</td>
<td colspan="1"><%= FieldInitialsError %><input type="text" name="Initials" value="<%= FieldInitials %>" maxlength="10" style="width:100%" class="TextBox<%= FieldInitialsClass %>" /></td>
</tr>
</table>
<table cellpadding="3" cellspacing="0" border="0" style="width:100%; table-layout:fixed;">
<colgroup>
<col style="width:100%;" />


<tr>
<td>By entering your initials, you acknowledge that this is a digital signature, equivalent to a signature on paper. </td>
</TR>
</colgroup>
<tr>
<td colspan="5" align="left">
<br>
<input type="image" name="Submit" src="/image/button/submit.gif" title="Submit">

</td>
</tr>

</table>


<a href="JavaScript:window.print();">Print this page for your records</a>
</form>


</div>


<!--#include virtual="/include/midder.asp"-->
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[vacunita]

We just needed to know it was ASP so we could direct you to the appropriate Forum.

Since the email can't be constructed with HTML alone it falls outside of the scope of this forum.

However the guys over at forum333 will happily help you out.

Remember to link to this thread when you create the new one there. Just copy this string: "thread215-1587063" into your message and it will automatically turn it into a link to this thread.

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Phil AKA Vacunita
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Ignorance is not necessarily Bliss, case in point:
Unknown has caused an Unknown Error on Unknown and must be shutdown to prevent damage to Unknown.

 

[vacunita]

Sorry the string should be: [ignore]thread215-1587063[/ignore] and it will turn it into the one above.

----------------------------------
Phil AKA Vacunita
----------------------------------
Ignorance is not necessarily Bliss, case in point:
Unknown has caused an Unknown Error on Unknown and must be shutdown to prevent damage to Unknown.

 

[Jiraf]

I suggest you to take form here -

http://phpforms.net/php-forms.html.

A resource that contains a specially designed to help you work with web forms.

 

[jcarmody]

So I guess you all now know what a novice I am at all of this. I think I've gotten things figured out. Thanks for your help.