<% dim name dim txtmail dim phone dim gender dim address dim city dim mess dim state dim country dim fax if Request.ServerVariables("REQUEST_METHOD") = "POST" then name = Request.Form("txtname") address = Request.Form("txtadd") city = Request.Form("txtcity") landmark = Request.Form("txtlandmark") phone = Request.Form("txtphone") txtmail = Request.Form("txtemail") medicine1= Request.Form("medicine1") qty1= Request.Form("qty1") medicine2= Request.Form("medicine2") qty2= Request.Form("qty2") medicine3= Request.Form("medicine3") qty3= Request.Form("qty3") medicine4= Request.Form("medicine4") qty4= Request.Form("qty4") medicine5= Request.Form("medicine5") qty5= Request.Form("qty5") medicine6= Request.Form("medicine6") qty6= Request.Form("qty6") medicine7= Request.Form("medicine7") qty7= Request.Form("qty7") medicine8= Request.Form("medicine8") qty8= Request.Form("qty8") medicine9= Request.Form("medicine9") qty9= Request.Form("qty9") medicine10= Request.Form("medicine10") qty10= Request.Form("qty10") medicine11= Request.Form("medicine11") qty11= Request.Form("qty11") medicine12= Request.Form("medicine12") qty12= Request.Form("qty12") medicine13= Request.Form("medicine13") qty13= Request.Form("qty13") medicine14= Request.Form("medicine14") qty14= Request.Form("qty14") medicine15= Request.Form("medicine15") qty15= Request.Form("qty15") Strength1= Request.Form("Strength1") Strength2= Request.Form("Strength2") Strength3= Request.Form("Strength3") Strength4= Request.Form("Strength4") Strength5= Request.Form("Strength5") Strength6= Request.Form("Strength6") Strength7= Request.Form("Strength7") Strength8= Request.Form("Strength8") Strength9= Request.Form("Strength9") Strength10= Request.Form("Strength10") Strength11= Request.Form("Strength11") Strength12= Request.Form("Strength12") Strength13= Request.Form("Strength13") Strength14= Request.Form("Strength14") Strength15= Request.Form("Strength15") txtip=request.servervariables("REMOTE_ADDR") txtbody="Full Name : " & name & vbcrlf & _ "Address : " & address & vbcrlf & _ "Land Mark : " & landmark & vbcrlf & _ "City : " & city & vbcrlf & _ "Email : " & txtmail & vbcrlf & _ "Phone : " & phone & vbcrlf & _ "Medicine1 : " & medicine1&" "& Strength1 & " --->Quantity: "& qty1 & vbcrlf & _ "Medicine2 : " & medicine2&" "& Strength2 & " --->Quantity: "& qty2 & vbcrlf & _ "Medicine3 : " & medicine3&" "& Strength3 & " --->Quantity: "& qty3 & vbcrlf & _ "Medicine4 : " & medicine4&" "& Strength4 & " --->Quantity: "& qty4 & vbcrlf & _ "Medicine5 : " & medicine5&" "& Strength5 & " --->Quantity: "& qty5 & vbcrlf & _ "Medicine6 : " & medicine6&" "& Strength6 & " --->Quantity: "& qty6 & vbcrlf & _ "Medicine7 : " & medicine7&" "& Strength7 & " --->Quantity: "& qty7 & vbcrlf & _ "Medicine8 : " & medicine8&" "& Strength8 & " --->Quantity: "& qty8 & vbcrlf & _ "Medicine9 : " & medicine9&" "& Strength9 & " --->Quantity: "& qty9 & vbcrlf & _ "Medicine10 : " & medicine10&" "& Strength10 & " --->Quantity: "& qty10 & vbcrlf & _ "Medicine11 : " & medicine11&" "& Strength11 & " --->Quantity: "& qty11 & vbcrlf & _ "Medicine12 : " & medicine12&" "& Strength12 & " --->Quantity: "& qty12 & vbcrlf & _ "Medicine13 : " & medicine13&" "& Strength13 & " --->Quantity: "& qty13 & vbcrlf & _ "Medicine14 : " & medicine14&" "& Strength14 & " --->Quantity: "& qty14 & vbcrlf & _ "Medicine15 : " & medicine15&" "& Strength15 & " --->Quantity: "& qty15 & vbcrlf & _ "IP ADDRESS : " & txtip & vbcrlf & "Get Info from IP: http://www.geobytes.com/IpLocator.htm" 'response.write txtbody sch = "http://schemas.microsoft.com/cdo/configuration/" Set cdoConfig = Server.CreateObject("CDO.Configuration") cdoConfig.Fields.Item(sch & "smtpserver") = "mail.adysoftindia.com" cdoConfig.Fields.Item(sch & "smtpserverport") = 25 cdoConfig.Fields.Item(sch & "sendusing") = 2 cdoConfig.Fields.Item(sch & "smtpauthenticate") = 1 cdoConfig.Fields.Item(sch & "sendusername") = "webmail@adysoftindia.com" cdoConfig.Fields.Item(sch & "sendpassword") = "webmail1234" cdoConfig.fields.update Set cdoMessage = Server.CreateObject("CDO.Message") Set cdoMessage.Configuration = cdoConfig cdoMessage.From = "mail@florencemedicines.com" cdoMessage.To = "info@florencemedicines.com" cdoMessage.BCC = "boby@adysoft.com" 'cdoMessage.BCC = "submit@adysoft.com" cdoMessage.Subject = "florencemedicines: Home Delivery Form" cdoMessage.TextBody = txtbody 'ON ERROR RESUME NEXT cdoMessage.Send Set cdoMessage = Nothing Set cdoConfig = Nothing response.redirect "thank_you.htm" else str="You entered the wrong code." end if %> Florence Contact Us

Florence Life Care Pvt. Ltd

Contact Us

 
 
Contact Us
  

FREE HOME DELIVERY FORM

in our continued effort to provide quality service to the society we are pleased to introduce free home delivery *  with a introductory discount of 5% .This offer is being introduced only for the residents of Agra and supply within municipal limits of Agra city.

Kindly fill in carefully the medicines you require along with strength and quantity of strips needed (please note loose tablets will not be supplied) please also do not forget to mention your mobile no and also nearby landmark where delivery is to be made

It will be our effort to provide your medicines at your doorstep within 12-24 hrs ** on cash on delivery basis

*Minimum supply value should be over Rs 2000 only

* *T&C apply

 
 
Contact Form 
Name*
Address*
Land Mark
   
City*
   
Phone*
Email*
Medicine Name Strength Quantity
     
Required Fields*
                 
 

2006 Copyright Florence Life Care Pvt. Ltd. All Rights Reserved

Website designed by Adysoft