<%@ LANGUAGE="VBScript" %> <% ' On Error Resume Next ' Classsic ASP pages created by Andre F Bruton ' E-mail: andre@bruton.co.za ' Date: 2008/01/19 namep = SQLEncode(Request("namep")) email = SQLEncode(Request("email")) intcode = SQLEncode(Request("intcode")) areacode = SQLEncode(Request("areacode")) phoneno = SQLEncode(Request("phoneno")) mobileintcode = SQLEncode(Request("mobileintcode")) mobile = SQLEncode(Request("mobile")) city = SQLEncode(Request("city")) states = SQLEncode(Request("states")) address = SQLEncode(Request("address")) comments = SQLEncode(Request("comments")) patientname = SQLEncode(Request("patientname")) patientemail = SQLEncode(Request("patientemail")) patientintcode = SQLEncode(Request("patientintcode")) patientareacode = SQLEncode(Request("patientareacode")) patientphone = SQLEncode(Request("patientphone")) patientmobileintcode = SQLEncode(Request("patientmobileintcode")) patientmobileno = SQLEncode(Request("patientmobileno")) patientcity = SQLEncode(Request("patientcity")) patientstate = SQLEncode(Request("patientstate")) patientaddress = SQLEncode(Request("patientaddress")) patientcomments = SQLEncode(Request("patientcomments")) status = SQLEncode(Request("status")) lookfor = SQLEncode(Request("lookfor")) recaptcha_challenge_field = Request("recaptcha_challenge_field") recaptcha_response_field = Request("recaptcha_response_field") recaptcha_private_key = "6LdTeLoSAAAAAC75m5T09Gjs9NIX-Naey4Al36My" recaptcha_public_key = "6LdTeLoSAAAAAOyq4XHU7Fx9ir_AGRUwHRFwdoow" browser = Request.ServerVariables("HTTP_USER_AGENT") ip = Request.ServerVariables("REMOTE_HOST") %> Refer a Patient to Indian IVF Clinics for IVF and Surrogacy
We Care Health Services
| Contact Us | Query |
Home Infertility Fertility Surrogacy Genetic Doctors

www.ivfsurrogacy.com
 
 
We Care Health Services IVF, Surrogacy, Surrogacy Mother IVF, Surrogacy, Surrogacy Mother IVF and Surrogacy : Success Rates and Testimonials IVF, Surrogacy, Surrogacy Mother  
 
 
10
 
 
10
 

10
About Us

10
 

10
About Us
InFertility Problem
Carrying Your Seeds
Loss Of The Fetus
Serious Genetic Disease
Choice For Egg Donation
Send a Quote
IVF Doctors In India
10
 

10
10
 

You are here : Home / Refer a Patient to Indian IVF Clinics for IVF and Surrogacy
Text :    

Refer a patient for  IVF treatment and Surrogacy to India
Are you a Gynaecologist, a General Practitioner, or are you involved in the healthcare service industry in your country? Do you want to refer a patient for IVF, Fertility, Egg Donation, Surrogacy or any other treatment in India.

If Yes, Please fill the given form and send us immediately:

Your Details

   

Your Name * :

 

Gender * :

  Male Female

Your E-Mail * :

 

Telephone *:

  Intl Code  

Area Code

Mobile *:

  Intl Code  

City *:

 

State *:

 

Country *:

 

Address * :

 

Your Message * :

 
   

Patients Details

   

Patient Name *:

 

Gender :

  Male Female

Patient E-Mail :

 

Telephone :

  Intl Code  

Area Code

Mobile :

  Intl Code  

City :

 

State :

 

Country *:

 

Address:

 

Message :

 

Clinical Status of the patient *:

 

Treatment Looking for *:

 

:

  <%=recaptcha_challenge_writer(recaptcha_public_key)%>
   
<% cTemp = recaptcha_confirm(recaptcha_private_key, recaptcha_challenge_field, recaptcha_response_field) If cTemp <> "" Then %>

An error occured with the recapture wording. Please try again. The error was Invalid Captcha Code


<% Else %> <% getemail=trim(Request.Form("email")) Dim iMsg Dim iConf Dim Flds Dim strHTML Dim strSmartHost dim email email=Request.Form("email") Const cdoSendUsingPort = 1 StrSmartHost = "mail.gmail.com" set iMsg = CreateObject("CDO.Message") set iConf = CreateObject("CDO.Configuration") dim strmess strmess="Query Form from IVF Surrogacy
" strmess=strmess & "
Contact Message
" strmess=strmess & "
Details of "& Request.Form("namep") & " 
" strmess=strmess & "
Your Name :     "& Request.Form("namep") & "" strmess=strmess & "
Gender :     "& Request.Form("gender") & "" strmess=strmess & "
Email :     "& email strmess=strmess & "
Telephone Number :     "& Request.Form("intcode") & "" strmess=strmess & "   -   "& Request.Form("areacode") & "" strmess=strmess & "   -   "& Request.Form("phoneno") & "" strmess=strmess & "
Mobile Number :     "& Request.Form("mobileintcode") & "" strmess=strmess & "   -   "& Request.Form("mobile") & "" strmess=strmess & "
City :     "& Request.Form("city") & "" strmess=strmess & "
State :     "& Request.Form("state") & "" strmess=strmess & "
Country :     "& Request.Form("country") & "" strmess=strmess & "
Address :     "& Request.Form("address") & "" strmess=strmess & "
Your Message :     "& Request.Form("comments") & "

" strmess=strmess & "
"& Request.Form("patientname") & "  Details
" strmess=strmess & "
Name :     "& Request.Form("patientname") & "" strmess=strmess & "
Gender :     "& Request.Form("patientgender") & "" strmess=strmess & "
Email :     "& Request.Form("patientemail") & "" strmess=strmess & "
Telephone Number :     "& Request.Form("patientintcode") & "" strmess=strmess & "   -   "& Request.Form("patientareacode") & "" strmess=strmess & "   -   "& Request.Form("patientphone") & "" strmess=strmess & "
Mobile Number :     "& Request.Form("patientmobileintcode") & "" strmess=strmess & "   -   "& Request.Form("patientmobileno") & "" strmess=strmess & "
City :     "& Request.Form("patientcity") & "" strmess=strmess & "
State :     "& Request.Form("patientstate") & "" strmess=strmess & "
Country :     "& Request.Form("patientcountry") & "" strmess=strmess & "
Address :     "& Request.Form("patientaddress") & "" strmess=strmess & "
Your Message :     "& Request.Form("patientcomments") & "" strmess=strmess & "
Clinical Status of the patient :     "& Request.Form("status") & "" strmess=strmess & "
Treatment Looking for :     "& Request.Form("lookfor") & "" Set Flds = iConf.Fields With Flds .Item("http://schemas.microsoft.com/cdo/configuration/sendusing") = cdoSendUsingPort .Item("http://schemas.microsoft.com/cdo/configuration/smtpserver") = strSmartHost .Item("http://schemas.microsoft.com/cdo/configuration/sendusername") = "info.wecareindia" .Item("http://schemas.microsoft.com/cdo/configuration/sendpassword") = "paperpaper" .Item("http://schemas.microsoft.com/cdo/configuration/smtpconnectiontimeout") = 10 .Item("http://schemas.microsoft.com/cdo/configuration/smtpserverport") = 26 .Item("http://schemas.microsoft.com/cdo/configuration/smtpauthenticate") = 1 .Item("http://schemas.microsoft.com/cdo/configuration/smtpserverpickupdirectory")="C:\Inetpub\mailroot\Pickup" .Update End With ' apply the settings to the message With iMsg Set .Configuration = iConf .To = "info.wecareindia@gmail.com" .BCC = "info.wecareindia@gmail.com" '.From = getemail .From = email '.From = "info.wecareindia@gmail.com" .Subject = "Query Form from IVF Surrogacy" .HTMLBody = strmess .Send End With ' cleanup of variables Set iMsg = Nothing Set iConf = Nothing Set Flds = Nothing Response.Redirect("thanks.htm") %> <% End If %> <% ' The code below supplied by Mark Short ' returns string the can be written where you would like the reCAPTCHA challenged placed on your page function recaptcha_challenge_writer(publickey) recaptcha_challenge_writer = "" & _ "" & _ "" end function function recaptcha_confirm(privkey,rechallenge,reresponse) ' Test the captcha field Dim VarString VarString = _ "privatekey=" & privkey & _ "&remoteip=" & Request.ServerVariables("REMOTE_ADDR") & _ "&challenge=" & rechallenge & _ "&response=" & reresponse Dim objXmlHttp Set objXmlHttp = Server.CreateObject("Msxml2.ServerXMLHTTP") objXmlHttp.open "POST", "http://api-verify.recaptcha.net/verify", False objXmlHttp.setRequestHeader "Content-Type", "application/x-www-form-urlencoded" objXmlHttp.send VarString Dim ResponseString ResponseString = split(objXmlHttp.responseText, vblf) Set objXmlHttp = Nothing if ResponseString(0) = "true" then ' They answered correctly recaptcha_confirm = "" else ' They answered incorrectly recaptcha_confirm = ResponseString(1) end if end function %>
We will contact you within 48 hrs of the receipt of this form on your phone number to have a personal discussion and facilitate for treatment in India.



^ Back to Top

For more information, medical assessment and medical quote
send your detailed medical history and medical reports
as email attachment to
Em@il : - info@wecareindia.com
Call: +91 9029304141 (10 am. To 8 pm. IST)
(Only for international patients seeking treatment in India)
You are here : Home / Refer a Patient to Indian IVF Clinics for IVF and Surrogacy
     
Send Response
 
         
         
         
  
Go Back Print This Page
Success
Other Procedures
India
Know More
For Professionals
Resources
Success Rates
Success Rates By Age
Happy Families
Pre Treatment Investigation
Laparoscopy Procedures
Cord Blood Banking
About India
Medical Tourism
Medical Visa
Stay in India
FAQ's
Facilities
Fully Inclusive Prices
IVF Centres
Be Our Associate
Corporates
Insurance
Refer a Patient
Affiliations
IVF News
Links
Blogs
Useful Info
Glossary
Related Links

Home   |   About Us   |   Site Map   |   Get a Quote  |   Disclaimer   |  Advertise With Us   |   Contact Us
Copyright 2009-2010 We Care India. All Rights Reserved.
Registered Office Mumbai : - 103, Gaurav Philips, Near Rishi Complex, Holy Cross Road, IC Colony, Borivali (West) Mumbai - 400103 Phone Number : +91 9029304141
Registered Office Delhi : - IB/5B, Phase - 1, Ashok Vihar, Delhi - 110052, India.
Valid HTML 4.01 Transitional Valid CSS! Digg Me !