<% function FieldOK(FieldName) if Request.Form(FieldName) = "" and Request.Form("send") then FieldOK = false else FieldOK = true end if end function function FieldWithDefaultOK(DefaultValue, FieldName) if Request.Form(FieldName) = DefaultValue and Request.Form("send") then FieldWithDefaultOK = false else FieldWithDefaultOK = true end if end function %>
If you would like to place an order for contact lenses, please complete the following form. We will be happy to mail them to you or you can pick them up at our office. One of our staff will call you to confirm you order.

All the fields followed by a * are mandatory.

<%if Request.Form("send") <> "" then if Request.Form("Prenom") = "" or FieldWithDefaultOk("Jour", "NaissanceJour") = false or FieldWithDefaultOk("Mois", "NaissanceMois") = false or FieldWithDefaultOk("Année", "NaissanceAnnee") = false or Request.Form("CodeRegional") = "" or Request.Form("Tel1") = "" or Request.Form("Tel2") = "" or FieldWithDefaultOk("Année", "ExamenAnnee") = false or FieldWithDefaultOk("Mois", "ExamenMois") = false or Request.Form("clinique") = "Choose" or Request.Form("Courriel") = "" then Response.Write("Please fill all mandatory fields *") end if end if if Request.Form("Prenom") <> "" and FieldWithDefaultOk("Jour", "NaissanceJour") and FieldWithDefaultOk("Mois", "NaissanceMois") and FieldWithDefaultOk("Année", "NaissanceAnnee") and Request.Form("CodeRegional") <> "" and Request.Form("Tel1") <> "" and Request.Form("Tel2") <> "" and FieldWithDefaultOk("Annee", "ExamenAnnee") and FieldWithDefaultOk("Mois", "ExamenMois") and (Request.Form("typeJetableDroit") <> "" or Request.Form("typeJetableGauche") <> "" ) and Request.Form("clinique") <> "Choose" and Request.Form("Courriel") <> "" then Set Mailer = Server.CreateObject("CDONTS.NewMail") ' Variable ajoutée par Max Dim bodyMail ' Construire le contenu du mail bodyMail = bodyMail & "Client First and Last Names: " & Request.Form("Titre") & " " & Request.Form("Prenom") & " " & Request.Form("Nom") & vbCrLf & vbCrLf bodyMail = bodyMail & "Date of birth : " & Request.Form("NaissanceJour") & " " & Request.Form("NaissanceMois") & " " & Request.Form("NaissanceAnnee") & vbCrLf & vbCrLf bodyMail = bodyMail & "Telephone: " & Request.Form("CodeRegional") & "-" & Request.Form("Tel1") & "-" & Request.Form("Tel2") & vbCrLf & vbCrLf bodyMail = bodyMail & "Email: " & Request.Form("Courriel") & vbCrLf & vbCrLf bodyMail = bodyMail & "Last Eye Exam: " & Request.Form("ExamenMois") & " " & Request.Form("ExamenAnnee") & vbCrLf & vbCrLf bodyMail = bodyMail & "Product Name: " & Request.Form("produit") & vbCrLf & vbCrLf bodyMail = bodyMail & "Eye: " & Request.Form("typeJetableDroit") & ", " & Request.Form("typeJetableGauche") & vbCrLf & vbCrLf bodyMail = bodyMail & "Re-order for: " & Request.Form("Quantite") & vbCrLf & vbCrLf bodyMail = bodyMail & "Number of boxes : " & Request.Form("boites") & vbCrLf & vbCrLf bodyMail = bodyMail & "Pick-up Location: " & Request.Form("clinique") & vbCrLf & vbCrLf bodyMail = bodyMail & "Remarks: " & Request.Form("remarques") & vbCrLf & vbCrLf bodyMail = bodyMail & "Wants to receive newsletters and promotionals: " & Request.Form("Newsletter") & vbCrLf Mailer.Body = bodyMail ' Envoyer le mail Mailer.From = Request.Form("Courriel") Mailer.To = "dr.robock@cogeco.net" Mailer.Cc = Request.Form("Courriel") Mailer.Subject = "Contact Lenses Order - Family Optometry Dr E.L Robock" Mailer.Send %>

// Your order has been sent.
We will contact you as soon as your contact lenses are ready for pick-up.
Thank You! //

<% else %>

Title: 
First name*:  " /> <% if FieldOk("Prenom") = false then Response.Write("Enter your First name") end if %>
Last name*: " /> <% if FieldOk("Prenom") = false then Response.Write("Enter your Last name") end if %>
Date of birth*:  <% if FieldWithDefaultOk("Day", "NaissanceJour") = false or FieldWithDefaultOk("Month", "NaissanceMois") = false or FieldWithDefaultOk("Year", "NaissanceAnnee") = false then Response.Write("Date mandatory") end if %>
Day time telephone*:  " /> " /> " /> <% if FieldOk("CodeRegional") = false or FieldOk("Tel1") = false or FieldOk("Tel2") = false then Response.Write("Telephone no. mandatory") end if %>
E-mail*:  " /> <% if FieldOk("Courriel") = false then Response.Write("E-mail mandatory") end if %>
(for confirmation email only, will not be given to a third party)
When was your last eye exam?  <% if FieldWithDefaultOk("Mois", "examenMois") = false or FieldWithDefaultOk("Année", "examenAnnee") = false then Response.Write("Date mandatory") end if %>
An annual eye exam is recommended to all contact lenses users.
Type of lenses required*:  Name of product:   " /> <% if ((FieldOk("typeJetableDroit") = false and FieldOk("typeJetableGAuche") = false) or (FieldOk("Quantite") = false) or FieldOk("produit") = false or FieldOk("boites") = false) and (FieldOk("typeRegulierOeilDroit") = false and FieldOk("typeRegulierOeilGauche") = false) then Response.Write("Mandatory Fields") end if %>
  Right Eye /> Left Eye />
  Quantity: 1 year /> 6 months /> 3 months />
  OR number of boxes: " />
Pick-up location*:  <% if Request.Form("clinique") = "Choose" then Response.Write("Choose a clinic") end if %>
Comments:
Would you be interested in being kept informed of clinic promotions, offers or updates? /> Yes /> No
 
<% end if %>