'. $subject .'

Dental problem: '. $_POST['dental_prob'] . '

I would like to correct my: '. $_POST['like'] . '

What Medications are you taking?: '. $_POST['medication'] . '

How long have you been missing teeth?: '. $_POST['time_miss_teeth'] . '

When your teeth were removed did they replace bone?: '. $_POST['replace'] . '

Age: '. $_POST['age'] . '

Sex: '. $_POST['sex'] . '

Do you currently wear dentures?: '. $_POST['dentures'].'

Full or Partial Dentures?: '. $_POST['dentures_type'] . '

Have you had Dental Implants in the past: '. $_POST['dental_implant'] . '

Are you interested in Financing?: '. $_POST['financing'] . '

Will you be using insurance or will you be paying in cash?: '. $_POST['pay_mode'] . '

What other dental procedures are you interested in?: '. $_POST['dental_procedure'] . '

Name: '. $_POST['name'] . '

Email: '. $_POST['email'] . '

Phone: '. $_POST['phone'] . '

Address: '. $_POST['address1'].'

City: '. $_POST['city'] . '

State: '. $_POST['state'] . '

Zip: '. $_POST['zip'] . '

'; $headers = 'MIME-Version: 1.0' . "\n"; $headers .= 'Content-type: text/html; charset=iso-8859-1' . "\n"; $headers .= 'From: '. $from . "\n"; mail($to, $subject, $message, $headers); q("insert into consultation set name='".$_POST['name']."',age='".$_POST['age']."',sex='".$_POST['sex']."', email='".$_POST['email']."',phone='".$_POST['phone']."',add1='".$_POST['address1']."', city='".$_POST['city']."',state='".$_POST['state']."',zip='".$_POST['zip']."',dental_prob='".$_POST['dental_prob']."',correct='".$_POST['like']."', medication='".$_POST['medication']."',time_miss_teeth='".$_POST['time_miss_teeth']."',replace_bone='".$_POST['replace']."', dentures='".$_POST['dentures']."',dentures_type='".$_POST['dentures_type']."',dental_implant='".$_POST['dental_implant']."', financing='".$_POST['financing']."',pay_mode='".$_POST['pay_mode']."',dental_procedure='".$_POST['dental_procedure']."'"); //event(0, "Contact Request"); $ERmsg='Your request was sent successfully.'; $name=''; $age=''; $sex=''; $email=''; $phone=''; $address1=''; $city=''; $state=''; $zip=''; $problem=''; $message=''; } // else // $ERmsg='Some required information was missing or invalid.'; } ?> Mini Dental Implant Solutions | Take a online consultation from MDI doctor

  Take an Online Consultation

For the Smile you've always wanted contact a Mini Dental Implant Dentist today! For a qualified MDIS dentist in your area please complete the form below and we'll put you in touch with local dentist within 24 hours.
'; foreach ($state_list as $key=>$value) $states .= ''; $states .= ''; ?>
Describe your dental problem (ex. Missing Teeth, Loose Dentures):*
I would like to correct my (ex: Top Teeth, Bottom Teeth, Front Teeth, All of my teeth): *
What Medications are you taking?:*
How long have you been missing teeth?:
When your teeth were removed did they replace bone?:
Your Age: *
Gender: * Male  Female
Do you currently wear dentures?:* Yes  No
If yes, Full or Partial Dentures?: Full Dentures   
Partial Dentures
Have you had Dental Implants in the past?: Yes  No
Are you interested in Financing?: Yes  No
Will you be using insurance or will you be paying in cash?: Insurance  Cash
What other dental procedures are you interested in?: teeth cleaning  
oral exam
fillings  
etc
Your Name: *
Your Address: *
Your City: *
Your State: *
Your Zip: *
Your Email: *
Your Phone: