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Please fill-in the following form with appropriate details. This will help us to find a prospective donor for you. |
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| The faster you fill-in the below form, the sooner we will be able to help you. |
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insert("bloodrequest",$excufld);
if($ans)
$dflag=1;
}
}
if($dflag==1)
{
echo "";
$obj->table("","60%","","lable","","","");
$obj->tr();
echo "
 | ";
echo "Your Request has been accepted .
We will contact you very soon. | ";
$obj->ctr();
$obj->ctable();
echo "";
}
?>
0)
{
include("c_error.php");
}
//**************************************** above one**********************
for($i=1;$i <= 150;$i++) $age[$i-1]=$i;
$bldcomp=array("Whole Blood Cell","Packed Red Blood Cell","Fresh Frozen Plazma","Plazma Apheresis","Platelets Apheresis","ALYX","Other");
$bldgrp=array("AB","A","B","O");
$rh=array("+","-");
$gender=array("Male","Female","Other");
echo "";
echo "
Blood seeker request form";
$obj->form("request","","post","");
$obj->table("","60%","","tt","lable","","","");
$obj->tr();
$obj->td();
echo "*";
echo "Name:";
echo " First ";
$obj->ctd();
$obj->td();
$obj->tx("fname","15","$fname","txtbx");
echo " Middle ";
$obj->tx("mname","16","$mname","txtbx");
echo " Last ";
$obj->ctd();
$obj->td();
$obj->tx("lname","15","$lname","txtbx");
$obj->ctd();
$obj->ctr();
$obj->ctr();
$obj->td("3","","","","right");
echo "(mm/dd/yyyy)";
$obj->ctd();
$obj->ctr();
$obj->ctr();
$obj->td();
echo "Sex:";
$obj->ctd();
$obj->td();
$obj->dp("sex",$gender,"1","","$sex","txtbx");
echo " Age: ";
$obj->dp("age",$age,"1","","$age","txtbx"); echo "(yrs)";
echo " *";
echo "Blood need on Date: ";
$obj->ctd();
$obj->td();
$obj->tx("nddt","15","$nddt","txtbx");
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
echo " Req. Blood Group:";
$obj->ctd();
$obj->td("2");
$obj->dp("bldgrp",$bldgrp,"1","","$bldgrp","txtbx");
echo " Rh Factor: ";
$obj->dp("rhfactor",$rh,"1","","$rhfactor","txtbx");
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td("","","","","","top");
echo "Blood Component: ";
$obj->ctd();
$obj->td();
$obj->dp("bldcomponent",$bldcomp,"1","","$bldcomponent","txtbx");
echo " Other: ";
$obj->ctd();
$obj->td();
$obj->tx("obldcmp","12","$obldcmp","txtbx");
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
echo "E-mail";
echo " 1.";
$obj->ctd();
$obj->td("2");
$obj->tx("email1","33","$email1","txtbx");
echo " 2. ";
$obj->tx("email2","30","$email2","txtbx");
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td("3");
$obj->table("","100%","","lable","","","");
$obj->tr();
$obj->td();
echo " ";
$obj->ctd();
$obj->tr();
$obj->tr();
echo"";
echo "Personnel Address:";
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
echo "*";
echo "Address Line1:";
$obj->ctd();
$obj->td("2");
$obj->tx("peraddress1","40","$peraddress1","txtbx");
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
echo "Address Line2:";
$obj->ctd();
$obj->td("2");
$obj->tx("peraddress2","40","$peraddress2","txtbx");
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
echo "City:";
$obj->ctd();
$obj->td();
$obj->tx("percty","15","$percty","txtbx");
echo " ";
echo " ";
echo " ";
echo " ";
echo "State:";
$obj->ctd();
$obj->td();
$obj->tx("perstate","15","$perstate","txtbx");
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
echo "Country:";
$obj->ctd();
$obj->td();
$obj->dp("percountry",$cun,"1","","$percountry","txtbx");
echo " ";
echo "Zip / Postal Code:";
$obj->ctd();
$obj->td();
$obj->tx("perzip","15","$perzip","txtbx");
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
echo "Phone No:";
echo " 1.";
$obj->ctd();
$obj->td();
$obj->tx("perphno1","15","$perphno1","txtbx");
echo " 2. ";
$obj->tx("perphno2","15","$perphno2","txtbx");
echo " Mobile:";
$obj->ctd();
$obj->td();
$obj->tx("permblno","15","$permblno","txtbx");
$obj->ctd();
$obj->ctr();
$obj->ctable();
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td("3");
$obj->table("","100%","","lable","","","");
$obj->tr();
$obj->td();
echo " ";
$obj->ctd();
$obj->tr();
$obj->tr();
echo" | ";
echo "Hospital / Nursing Home Address:";
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
echo "*";
echo "Address Line1:";
$obj->ctd();
$obj->td("2");
$obj->tx("hosaddress1","40","$hosaddress1","txtbx");
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
echo "Address Line2:";
$obj->ctd();
$obj->td("2");
$obj->tx("hosaddress2","40","$hosaddress2","txtbx");
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
echo "City:";
$obj->ctd();
$obj->td();
$obj->tx("hoscty","15","$hoscty","txtbx");
echo " ";
echo " ";
echo " ";
echo " ";
echo "State:";
$obj->ctd();
$obj->td();
$obj->tx("hosstate","15","$hosstate","txtbx");
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
echo "Country:";
$obj->ctd();
$obj->td();
$obj->dp("hoscountry",$cun,"1","","$hoscountry","txtbx");
echo " ";
echo "Zip / Postal Code:";
$obj->ctd();
$obj->td();
$obj->tx("hoszip","15","$hoszip","txtbx");
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
echo "Phone No:";
echo " 1.";
$obj->ctd();
$obj->td();
$obj->tx("hosphno1","15","$hosphno1","txtbx");
echo " 2. ";
$obj->tx("hosphno2","15","$hosphno2","txtbx");
echo " Mobile:";
$obj->ctd();
$obj->td();
$obj->tx("hosmblno","15","$hosmblno","txtbx");
$obj->ctd();
$obj->ctr();
$obj->ctable();
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
echo " ";
$obj->ctd();
$obj->tr();
$obj->tr();
$obj->td("","","","","","top");
echo "Request Reason:";
$obj->ctd();
$obj->td("2");
$obj->txr("reason","38","3","$reason","txtbx");
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td("","","","","","top");
echo "Remarks:";
$obj->ctd();
$obj->td("2");
$obj->txr("remarks","38","3","$remarks","txtbx");echo "
";
$obj->ctd();
$obj->ctr();
$obj->tr();
$obj->td();
echo " ";
$obj->ctd();
$obj->td("","","","","center");
$obj->sb("Submit","Submit");echo " ";
$obj->rs("Reset","Reset");
$obj->ctd();
$obj->ctr();
$obj->ctable();
echo "";
$obj->cform();
}
?>
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