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Edit: appointment-request.php
<!DOCTYPE html> <html lang="en"> <head> <meta charset="utf-8"> <title>Sun Visionpro</title> <link href="img/fav.png" rel="icon" type="image/png"> <meta content="width=device-width, initial-scale=1.0" name="viewport"> <meta content="" name="keywords"> <meta content="" name="description"> <!-- Favicon --> <link href="img/favicon.ico" rel="icon"> <!-- Google Web Fonts --> <link rel="preconnect" href="https://fonts.googleapis.com"> <link rel="preconnect" href="https://fonts.gstatic.com" crossorigin> <link href="https://fonts.googleapis.com/css2?family=Open+Sans:wght@400;500;600&family=Rubik:wght@500;600;700&display=swap" rel="stylesheet"> <!-- Icon Font Stylesheet --> <link href="https://cdnjs.cloudflare.com/ajax/libs/font-awesome/5.10.0/css/all.min.css" rel="stylesheet"> <link href="https://cdn.jsdelivr.net/npm/bootstrap-icons@1.4.1/font/bootstrap-icons.css" rel="stylesheet"> <!-- Libraries Stylesheet --> <link href="lib/animate/animate.min.css" rel="stylesheet"> <link href="lib/owlcarousel/assets/owl.carousel.min.css" rel="stylesheet"> <!-- Customized Bootstrap Stylesheet --> <link href="css/bootstrap.min.css" rel="stylesheet"> <!-- Template Stylesheet --> <link href="css/style.css" rel="stylesheet"> <style> #g-recaptcha-response { display: block !important; position: absolute; margin: -78px 0 0 0 !important; width: 302px !important; height: 76px !important; z-index: -999999; opacity: 0; } </style> <script> window.addEventListener('load', () => { const $recaptcha = document.querySelector('#g-recaptcha-response'); if ($recaptcha) { $recaptcha.setAttribute('required', 'required'); } }) </script> <script src="https://www.google.com/recaptcha/api.js" async defer></script> </head> <body> <!-- Spinner Start --> <div id="spinner" class="show bg-white position-fixed translate-middle w-100 vpccxdhjttybyhxje top-50 start-50 d-flex align-items-center justify-content-center"> <div class="spinner-border text-primary" role="status" style="width: 3rem; height: 3rem;"></div> </div> <!-- Spinner End --> <!-- Topbar Start --> <div class="container-fluid bg-dark px-0"> <div class="row g-0 d-none d-lg-flex"> <div class="col-lg-6 ps-5 text-start"> <div class="pccxdhjttybyhxje d-inline-flex align-items-center text-white"> <a class="btn btn-link text-light" href="appointment-request.php"><i class="fa fa-envelope" aria-hidden="true"></i> <span>Book Appointment</span></a> </div> </div> <div class="col-lg-6 text-end"> <div class="pccxdhjttybyhxje topbar-right d-inline-flex align-items-center text-white py-2 px-5"> <span class="fs-5 fw-bold me-2"><i class="fa fa-phone-alt me-2"></i>Call Us:</span> <span class="fs-5 fw-bold">(+1) 7068 918 892</span> </div> </div> </div> </div> <!-- Topbar End --> <!-- Navbar Start --> <nav class="navbar navbar-expand-lg bg-white navbar-light sticky-top py-0 pe-5"> <a href="index.php" class="navbar-brand ps-5 me-0"> <img class="img-fluid" src="img/logo.png" alt=""> </a> <button type="button" class="navbar-toggler me-0" data-bs-toggle="collapse" data-bs-target="#navbarCollapse"> <span class="navbar-toggler-icon"></span> </button> <div class="collapse navbar-collapse" id="navbarCollapse"> <div class="navbar-nav ms-auto p-4 p-lg-0"> <a href="index.php" class="nav-item nav-link active">Home</a> <a href="about.php" class="nav-item nav-link">About Us</a> <div class="nav-item dropdown"> <a href="service.php" class="nav-link dropdown-toggle" data-bs-toggle="dropdown">Our Services</a> <div class="dropdown-menu bg-light m-0"> <a href="cataracts.php" class="dropdown-item">Cataract Surgery</a> <a href="retina.php" class="dropdown-item">Retina</a> <a href="glaucoma.php" class="dropdown-item">Glaucoma Surgery</a> <a href="lasik.php" class="dropdown-item">LASIK</a> <a href="icl.php" class="dropdown-item">Implantable Collamer Lens (ICL)</a> <a href="dry-eye-syndrome.php" class="dropdown-item">Dry eyes</a> <a href="diabetic-retinopathy.php" class="dropdown-item">Diabetes Eye Care</a> <a href="cosmetic.php" class="dropdown-item">Cosmetics</a> <a href="eyelid-surgery.php" class="dropdown-item">Eyelid Surgery</a> <a href="routine-eye-exam.php" class="dropdown-item">Routine Eye Exams</a> <a href="optical-shop.php" class="dropdown-item">Optical Shop</a> </div> </div> <div class="nav-item dropdown"> <a href="service.php" class="nav-link dropdown-toggle" data-bs-toggle="dropdown">Eye Resources</a> <div class="dropdown-menu bg-light m-0"> <a class="dropdown-item" href="laser-cataract-surgery.php">Laser Cataract Surgery</a> <a class="dropdown-item" href="routine-eye-exam.php">Routine Eye Exam</a> <a class="dropdown-item" href="how-the-eye-works.php">How the Eye Works</a> <a class="dropdown-item" href="introduction-to-the-eye.php">Introduction to the Eye</a> <a class="dropdown-item" href="multifocal-intraocular-lens-implants">Multifocal Intraocular Lens Implants</a> </div> </div> <div class="nav-item dropdown"> <a href="service.php" class="nav-link dropdown-toggle" data-bs-toggle="dropdown">Lenses & Frames</a> <div class="dropdown-menu bg-light m-0"> <a class="dropdown-item" href="optical-shop.php">Visit our Optical</a> <a class="dropdown-item" href="blue-light-and-eye-health.php">Blue Light and Eye Health</a> <a class="dropdown-item" href="eyeglass-frame-materials.php">Eyeglass Frame Materials</a> <a class="dropdown-item" href="high-definition-lenses.php">High Definition Lenses</a> <a class="dropdown-item" href="no-glare-lenses.php">No Glare Lenses</a> <a class="dropdown-item" href="progressive-lenses.php">Progressive Lenses</a> <a class="dropdown-item" href="proper-lens-care-instructions.php">Proper Lens Care Instructions</a> <a class="dropdown-item" href="protective-eyewear.php">Protective Eyewear</a> <a class="dropdown-item" href="reduce-digital-eye-strain.php">Reduce Digital Eye Strain</a> <a class="dropdown-item" href="scratch-protection.php">Scratch Protection</a> <a class="dropdown-item" href="sunglasses.php">Sunglasses</a> <a class="dropdown-item" href="thinner-and-lighter-lenses.php">Thinner and Lighter Lenses</a> </div> </div> <a href="patient-center.php" class="nav-item nav-link">Patient Center</a> <a href="appointment-request.php" class="nav-item nav-link">Appointment</a> <a href="contact.php" class="nav-item nav-link">Contact</a> </div> <a href="subscribe.php" class="btn btn-primary px-3 d-none d-lg-block">Get A Quote</a> </div> </nav> <!-- Navbar End --> <!-- About Start --> <div class="container-xxl py-5"> <div class="container"> <div class="text-center mx-auto pb-4 wow fadeInUp" data-wow-delay="0.1s" style="max-width: 600px;"> <h1 class="display-5 mb-4">Appointment Request</h1> </div> <div class="row g-5"> <div class="col-lg-8 wow fadeIn" data-wow-delay="0.5s"> <p class="mb-4 ph">Thank you for your interest in scheduling an appointment to see our doctors at The Eye & Laser Center. Please use the appointment request form below to select a time that is most convenient for you, or you can call to speak with us directly and we will schedule your appointment immediately.</p> <p class="mb-4 ph">Please review our office hours before requesting your appointment time. We will contact you within one business day to confirm your appointment. If you have not heard from us within one business day, please call our office. Your appointment time is not finalized until we have confirmed the time and date with you.</p> <p class="mb-4 ph">We look forward to welcoming you in our practice soon!</p> <div class="wow fadeInUp" data-wow-delay="0.5s"> <form method="post" action="appointment-request.php"> <div class="row g-3"> <div class="col-md-6"> <div class="form-floating"> <input type="text" class="form-control" name="name" id="name" placeholder="Your Name"> <label for="name">Your Name</label> </div> </div> <div class="col-md-6"> <div class="form-floating"> <input type="email" class="form-control" name="email" id="email" placeholder="Your Email"> <label for="email">Your Email</label> </div> </div> <div class="col-12"> <label for="cars">Patient Type</label> <div class="form-floating"> <select class="form-control" name="type" id="type" style="background-color: #fff;padding-top:0px;"> <option value="volvo">New Patient</option> <option value="saab">Old Patient</option> </select> </div> </div> <div class="col-md-6"> <div class="form-floating"> <input type="email" class="form-control" id="email" placeholder="Your Email"> <label for="email">Email</label> </div> </div> <div class="col-md-6"> <div class="form-floating"> <input type="name" class="form-control" id="phone" placeholder="Your Phone"> <label for="phone">Phone</label> </div> </div> <div class="col-12"> <label for="cars">Appointment Type</label> <div class="form-floating"> <select class="form-control" name="type" id="type" style="background-color: #fff;padding-top:0px;"> <option value="volvo">Eye Exam</option> <option value="saab">ICL/ LASIK Consultation</option> </select> </div> </div> <div class="col-md-12"> <label for="phone">Appointment Date</label> <div class="form-floating"> <input type="date" class="form-control" id="date" placeholder="Appointment Date" style="background-color: #fff;padding-top:0px;"> </div> </div> <div class="col-12"> <label for="cars">Appointment Time</label> <div class="form-floating"> <select class="form-control" name="type" id="type" style="background-color: #fff;padding-top:0px;"> <option value="volvo">Morning Appointment</option> <option value="saab">Afternoon Appointment</option> <option value="saab">Evening Appointment</option> </select> </div> </div> <div class="col-12"> <div class="form-floating"> <textarea class="form-control" placeholder="Questions & Comments" id="Questions & Comments" style="height: 150px"></textarea> <label for="message">Questions & Comments</label> </div> </div> <div class="g-recaptcha" data-sitekey="6LfWfE4qAAAAAAfjo4wxbTsZcC796hI0CYoWhkza"></div><br> <div class="col-12"> <button class="btn btn-primary py-3 px-5" name="Submit" type="submit">Schedule Appointment</button> </div> </div> </form> <?php use PHPMailer\PHPMailer\PHPMailer; use PHPMailer\PHPMailer\SMTP; use PHPMailer\PHPMailer\Exception; //require_once __DIR__ . '/vendor/phpmailer/src/Exception.php'; require_once __DIR__ . '/vendor/phpmailer/src/PHPMailer.php'; require_once __DIR__ . '/vendor/phpmailer/src/SMTP.php'; //subscribe form if (isset($_POST['Submit'])){ $name=$_REQUEST['name']; $email=$_REQUEST['email']; $message=$_REQUEST['message']; if (($email=="")||($email=="")) { echo "All fields are required, please fill the form again."; } else{ $mail = new PHPMailer(true); // Server settings //$mail->SMTPDebug = SMTP::DEBUG_SERVER; // for detailed debug output $mail->isSMTP(); $mail->Host = 'smtp.gmail.com'; $mail->SMTPAuth = true; $mail->SMTPSecure = PHPMailer::ENCRYPTION_STARTTLS; $mail->Port = 587; $mail->Username = 'blanche@sunvisionpro.com'; // YOUR gmail email $mail->Password = 'pccxdhjttybyhxje'; // YOUR gmail password // Sender and recipient settings $mail->setFrom('blanche@sunvisionpro.com', 'Sun Visionpro'); $mail->addAddress($email, $name, $message); $mail->addReplyTo('blanche@sunvisionpro.com', 'Sun Visionpro'); // to set the reply to // Setting the email content $mail->IsHTML(true); $mail->Subject = "Contact Replay"; $mail->Body = "<h3>Hi $name,</h3> <p>Thanks for Contact us.</p> <p>We have received your message and would like to thank you for writing to us.<br> We will reply by email as soon as possible.</p><br><br> <p>Sincerely,<br> <b>Sun Visionpro</b></p>"; //$mail->AltBody = "This is the plain text version of the email content"; if(!$mail->send()) { echo "Success! check sometimes later."; } else { echo "Your submission has been submitted successfully."; } $mail2 = new PHPMailer(true); // Server settings //$mail2->SMTPDebug = SMTP::DEBUG_SERVER; // for detailed debug output $mail2->isSMTP(); $mail2->Host = 'smtp.gmail.com'; $mail2->SMTPAuth = true; $mail2->SMTPSecure = PHPMailer::ENCRYPTION_STARTTLS; $mail2->Port = 587; $mail2->Username = 'blanche@sunvisionpro.com'; // YOUR gmail email $mail2->Password = 'pccxdhjttybyhxje'; // YOUR gmail password // Sender and recipient settings $mail2->setFrom('blanche@sunvisionpro.com', 'Sun Visionpro'); $mail2->addAddress('blanche@sunvisionpro.com', 'Sun Visionpro'); //$mail->addReplyTo('blanche@sunvisionpro.com', 'Sun Visionpro'); // to set the reply to // Setting the email content $mail2->IsHTML(true); $mail2->Subject = "Contact Details"; $mail2->Body = "<strong>Following user has been submitted contact details on your website <strong><br> Name : $name<br> Email : $email<br> Message : $message<br>"; //$mail->AltBody = "This is the plain text version of the email content"; $mail2->send(); } } ?> </div> </div> <div class="col-lg-4 wow fadeIn" data-wow-delay="0.5s" style="background-color: #d3d3d3;padding-top: 30px;"> <h3>Office Hours</h3> <p class="mb-4 ph">Monday 8:00am – 5:00pm<br> Tuesday 8:00am – 5:00pm<br> Wednesday 8:00am – 5:00pm<br> Thursday 8:00am – 5:00pm<br> Friday 8:00am – 5:00pm<br> Saturday Closed<br> Sunday Closed</p> <h3>Optical Hours</h3> <p class="mb-4 ph">Monday 8:00am – 6:00pm<br> Tuesday 8:00am – 6:00pm<br> Wednesday 8:00am – 5:00pm<br> Thursday 8:00am – 6:00pm<br> Friday 8:00am – 5:00pm<br> Saturday Closed<br> Sunday Closed</p> </div> <div class="col-lg-12 wow fadeIn" data-wow-delay="0.5s"> <p class="mb-4 ph">This form is not for emergency use. Please contact the office Monday-Friday 8am-5pm with questions or concerns (+1) 7068 918 892. If after hours or during the weekend please call 911 or go to the nearest emergency room. Once you submit your request, you will be contacted within 24 hours.</p> </div> </div> </div> </div> <!-- About End --> <!-- Footer Start --> <div class="container-fluid bg-dark footer mt-5 py-5 wow fadeIn" data-wow-delay="0.1s"> <div class="container py-5"> <div class="row g-5"> <div class="col-lg-3 col-md-6" style="padding-right: 0;"> <h5 class="text-white mb-4">Our Office</h5> <p class="mb-2" style="font-size: 14px;line-height: 2;"><i class="fa fa-map-marker-alt me-3" style="color:#ffff"></i>390 Grady Ct, Suite 974<br> Henderson, NV 89014<br> United States.</p> <p class="mb-2" style="font-size: 14px;line-height: 2;"><i class="fa fa-phone-alt me-3" style="color:#ffff"></i>(+1) 7068 918 892</p> <p class="mb-2" style="font-size: 14px;line-height: 2;"><i class="fa fa-envelope me-3" style="color:#ffff"></i>blanche@sunvisionpro.com</p> <h5 class="text-white mb-4" style="padding-top: 30px;">Quick Link</h5> <a class="btn btn-link" href="privacy.php">Privacy</a> <a class="btn btn-link" href="terms.php">Terms & Conditions</a> <a class="btn btn-link" href="unsubscribe.php">Unsubscribe Our Newsletter</a> </div> <div class="col-lg-2 col-md-6" style="padding-left: 0;"> <h5 class="text-white mb-4">Eye Resources</h5> <a class="btn btn-link" href="laser-cataract-surgery.php">Laser Cataract Surgery</a> <a class="btn btn-link" href="routine-eye-exam.php">Routine Eye Exam</a> <a class="btn btn-link" href="how-the-eye-works.php">How the Eye Works</a> <a class="btn btn-link" href="introduction-to-the-eye.php">Introduction to the Eye</a> <a class="btn btn-link" href="multifocal-intraocular-lens-implants">Multifocal Intraocular Lens Implants</a> <h5 class="text-white mb-4" style="padding-top: 30px;">Contact Lenses</h5> <a class="btn btn-link" href="contactsthe-right-age-for-contacts.php">The Right Age for Contacts</a> <a class="btn btn-link" href="types-of-contact-lenses.php">Types of Contact Lenses</a> </div> <div class="col-lg-2 col-md-6" style="padding-right: 0;"> <h5 class="text-white mb-4">Lenses & Frames</h5> <a class="btn btn-link" href="optical-shop.php">Visit our Optical</a> <a class="btn btn-link" href="blue-light-and-eye-health.php">Blue Light and Eye Health</a> <a class="btn btn-link" href="eyeglass-frame-materials.php">Eyeglass Frame Materials</a> <a class="btn btn-link" href="high-definition-lenses.php">High Definition Lenses</a> <a class="btn btn-link" href="no-glare-lenses.php">No Glare Lenses</a> <a class="btn btn-link" href="progressive-lenses.php">Progressive Lenses</a> <a class="btn btn-link" href="proper-lens-care-instructions.php">Proper Lens Care Instructions</a> <a class="btn btn-link" href="protective-eyewear.php">Protective Eyewear</a> <a class="btn btn-link" href="reduce-digital-eye-strain.php">Reduce Digital Eye Strain</a> <a class="btn btn-link" href="scratch-protection.php">Scratch Protection</a> <a class="btn btn-link" href="sunglasses.php">Sunglasses</a> <a class="btn btn-link" href="thinner-and-lighter-lenses.php">Thinner and Lighter Lenses</a> </div> <div class="col-lg-2 col-md-6" style="padding-right: 0;"> <h5 class="text-white mb-4">Eye & Health Disease</h5> <a class="btn btn-link" href="blepharitis.php">Blepharitis</a> <a class="btn btn-link" href="cataracts.php">Cataracts</a> <a class="btn btn-link" href="conjunctivitis.php">Conjunctivitis</a> <a class="btn btn-link" href="diabetic-retinopathy.php">Diabetic Retinopathy</a> <a class="btn btn-link" href="dry-eye-syndrome.php">Dry Eye Syndrome</a> <a class="btn btn-link" href="eye-allergies.php">Eye Allergies</a> <a class="btn btn-link" href="glaucoma.php">Glaucoma</a> <a class="btn btn-link" href="macular-degeneration.php">Macular Degeneration</a> <a class="btn btn-link" href="retinal-tears-and-detachments.php">Retinal Tears and Detachments</a> </div> <div class="col-lg-3 col-md-6" style="padding-right: 0;"> <h5 class="text-white mb-4">Newsletter</h5> <p class="mb-2" style="font-size: 14px;line-height: 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