ChronoEngine.com - Professional Joomla Work - Re:Optical Contact / Request Information form

	ChronoEngine Forums	Forum Threaded View Rules

Welcome, Guest
Please Login or Register. Lost Password?

ChronoEngine Forums

ChronoForms Forums

Share your forms with others

Re:Optical Contact / Request Information form (1 viewing) (1) Guest

Favoured: 0

TOPIC: Re:Optical Contact / Request Information form

Forum Tools

#2013

laurel (Admin)

Admin

Posts: 26

Optical Contact / Request Information form 10 Months, 1 Week ago Karma: 0

A contact form for an optician, visitors can request appointments, information on different topics, or other. The form is inserted into a content page by using the mambot.

Code:

&lt;p&gt;Your Name:    &lt;input type=&quot;text&quot; name=&quot;name&quot; size=&quot;42&quot;&gt;&lt;/p&gt;
&lt;p&gt;Address: &lt;input type=&quot;text&quot; name=&quot;street&quot; size=&quot;42&quot;&gt;&lt;/p&gt;
&lt;p&gt;City: &lt;input type=&quot;text&quot; name=&quot;city&quot; size=&quot;20&quot;&gt;  State &lt;input type=&quot;text&quot; name=&quot;state&quot; size=&quot;3&quot; value=&quot;AR&quot;&gt;  Zip Code &lt;input type=&quot;text&quot; name=&quot;zip&quot; size=&quot;10&quot;&gt;&lt;/p&gt;
&lt;p&gt;Day Phone: &lt;input type=&quot;text&quot; name=&quot;day_phone&quot; size=&quot;20&quot;&gt;         &lt;/p&gt;
&lt;p&gt;Evening Phone: &lt;input type=&quot;text&quot; name=&quot;night_phone&quot; size=&quot;20&quot;&gt;&lt;/p&gt;
&lt;p&gt;E-mail: &lt;input type=&quot;text&quot; name=&quot;email&quot; size=&quot;40&quot;&gt;&lt;/p&gt;
&lt;hr&gt;
&lt;p&gt;&lt;strong&gt;Would you like to schedule an appointment?&lt;/strong&gt;     &lt;input type=&quot;radio&quot; name=&quot;appt&quot; value=&quot;YES_appt&quot; id=&quot;ff_elem183&quot;&gt; &lt;label id=&quot;ff_lbl183&quot; for=&quot;ff_elem183&quot;&gt;Yes &lt;/label&gt;
&lt;input type=&quot;radio&quot; name=&quot;appt&quot; value=&quot;NO_appt&quot; id=&quot;ff_elem184&quot;&gt; &lt;label id=&quot;ff_lbl184&quot; for=&quot;ff_elem184&quot;&gt;No &lt;/label&gt;&lt;/p&gt;
&lt;p&gt;Please provide us with information about &lt;br&gt;
when you would like an appointment. &lt;br&gt;
We will call, write, or e-mail you &lt;br&gt;
with an appointment confirmation. &lt;/p&gt;
&lt;blockquote&gt;
&lt;p&gt;&lt;strong&gt;Month &lt;/strong&gt;
&lt;select NAME=&quot;month&quot; id=&quot;ff_elem203&quot; size=&quot;1&quot;&gt;
  &lt;option SELECTED VALUE=&quot;none&quot;&gt;Select Month&lt;/option&gt;
  &lt;option VALUE=&quot;Jan&quot;&gt;Jan&lt;/option&gt;
  &lt;option VALUE=&quot;Feb&quot;&gt;Feb&lt;/option&gt;
  &lt;option VALUE=&quot;Mar&quot;&gt;Mar&lt;/option&gt;
  &lt;option VALUE=&quot;Apr&quot;&gt;Apr&lt;/option&gt;
  &lt;option VALUE=&quot;May&quot;&gt;May&lt;/option&gt;
  &lt;option VALUE=&quot;Jun&quot;&gt;Jun&lt;/option&gt;
  &lt;option VALUE=&quot;Jul&quot;&gt;Jul&lt;/option&gt;
  &lt;option VALUE=&quot;Aug&quot;&gt;Aug&lt;/option&gt;
  &lt;option VALUE=&quot;Sep&quot;&gt;Sep&lt;/option&gt;
  &lt;option VALUE=&quot;Oct&quot;&gt;Oct&lt;/option&gt;
  &lt;option VALUE=&quot;Nov&quot;&gt;Nov&lt;/option&gt;
  &lt;option VALUE=&quot;Dec&quot;&gt;Dec&lt;/option&gt;
&lt;/select&gt;&lt;/p&gt;
&lt;p&gt;&lt;strong&gt;Day&lt;/strong&gt;
&lt;select NAME=&quot;day&quot; id=&quot;ff_elem204&quot; size=&quot;1&quot;&gt;
  &lt;option VALUE=&quot;none&quot;&gt;Select Day&lt;/option&gt;
  &lt;option VALUE=&quot;Monday&quot;&gt;Monday&lt;/option&gt;
  &lt;option VALUE=&quot;Tuesday&quot;&gt;Tuesday&lt;/option&gt;
  &lt;option VALUE=&quot;Wednesday&quot;&gt;Wednesday&lt;/option&gt;
  &lt;option VALUE=&quot;Thursday&quot;&gt;Thursday&lt;/option&gt;
  &lt;option VALUE=&quot;Friday&quot;&gt;Friday&lt;/option&gt;
&lt;/select&gt;&lt;/p&gt;
&lt;p&gt;&lt;strong&gt;Time&lt;/strong&gt;
&lt;input TYPE=&quot;radio&quot; NAME=&quot;time&quot; VALUE=&quot;morning&quot; id=&quot;ff_elem185&quot;&gt;
&lt;label id=&quot;ff_lbl185&quot; for=&quot;ff_elem185&quot;&gt;Morning &lt;/label&gt;  
&lt;input TYPE=&quot;radio&quot; NAME=&quot;time&quot; VALUE=&quot;afternoon&quot; id=&quot;ff_elem186&quot;&gt;
&lt;label id=&quot;ff_lbl186&quot; for=&quot;ff_elem186&quot;&gt;Afternoon &lt;/label&gt;&lt;/p&gt;
&lt;/blockquote&gt;
&lt;hr align=&quot;left&quot;&gt;
&lt;p&gt;&lt;strong&gt;I would like additional information about:&lt;/strong&gt; &lt;/p&gt;
&lt;div align=&quot;left&quot;&gt;
&lt;table border=&quot;0&quot; width=&quot;469&quot; id=&quot;table4&quot; align=&quot;left&quot;&gt;
  &lt;tr&gt;
    &lt;td width=&quot;155&quot;&gt;
      &lt;p&gt;&lt;input TYPE=&quot;checkbox&quot; NAME=&quot;ff_nm_LASIK[]&quot; VALUE=&quot;info&quot; id=&quot;ff_elem193&quot;&gt;
      &lt;label id=&quot;ff_lbl193&quot; for=&quot;ff_elem193&quot;&gt;LASIK &lt;/label&gt;&lt;/p&gt;
      &lt;p&gt;&lt;input TYPE=&quot;checkbox&quot; NAME=&quot;ff_nm_Contacts[]&quot; VALUE=&quot;info&quot; id=&quot;ff_elem194&quot;&gt;
      &lt;label id=&quot;ff_lbl194&quot; for=&quot;ff_elem194&quot;&gt;Contacts &lt;/label&gt;
    &lt;/td&gt;
    &lt;td width=&quot;156&quot;&gt;
      &lt;p&gt;&lt;input TYPE=&quot;checkbox&quot; NAME=&quot;ff_nm_Glasses[]&quot; VALUE=&quot;info&quot; id=&quot;ff_elem195&quot;&gt; 
      &lt;label id=&quot;ff_lbl195&quot; for=&quot;ff_elem195&quot;&gt;Glasses &lt;/label&gt;&lt;/p&gt;
      &lt;p&gt;&lt;input TYPE=&quot;checkbox&quot; NAME=&quot;ff_nm_Cataracts[]&quot; VALUE=&quot;info&quot; id=&quot;ff_elem196&quot;&gt; 
      &lt;label id=&quot;ff_lbl196&quot; for=&quot;ff_elem196&quot;&gt;Cataracts &lt;/label&gt;
    &lt;/td&gt;
    &lt;td width=&quot;156&quot;&gt;
      &lt;p&gt;&lt;input TYPE=&quot;checkbox&quot; NAME=&quot;ff_nm_Glaucoma[]&quot; VALUE=&quot;info&quot; id=&quot;ff_elem197&quot;&gt; 
      &lt;label id=&quot;ff_lbl197&quot; for=&quot;ff_elem197&quot;&gt;Glaucoma &lt;/label&gt;&lt;/p&gt;
      &lt;p&gt;&lt;input TYPE=&quot;checkbox&quot; NAME=&quot;ff_nm_Eyelid_Surgery[]&quot; VALUE=&quot;info&quot; id=&quot;ff_elem198&quot;&gt; 
      &lt;label id=&quot;ff_lbl198&quot; for=&quot;ff_elem198&quot;&gt;Eyelid Surgery &lt;/label&gt;
    &lt;/td&gt;
  &lt;/tr&gt;
&lt;/table&gt;
&lt;/div&gt;
&lt;p&gt;&lt;input TYPE=&quot;checkbox&quot; NAME=&quot;ff_nm_Other[]1&quot; VALUE=&quot;info&quot; id=&quot;ff_elem199&quot;&gt; 
&lt;label id=&quot;ff_lbl199&quot; for=&quot;ff_elem199&quot;&gt;Other Information or Questions: &lt;/label&gt;&lt;/p&gt;
&lt;p&gt;&lt;textarea COLS=&quot;30&quot; NAME=&quot;other_info&quot; id=&quot;ff_elem192&quot; style=&quot;height: 63; width: 612&quot; rows=&quot;3&quot;&gt;&lt;/textarea&gt;&lt;/p&gt;
&lt;hr&gt;
&lt;p&gt;The best way to contact me:
&lt;input type=&quot;checkbox&quot; name=&quot;contact&quot; value=&quot;mail&quot;&gt; Mail 
&lt;input type=&quot;checkbox&quot; name=&quot;contact&quot; value=&quot;phone&quot;&gt; Telephone 
&lt;input type=&quot;checkbox&quot; name=&quot;contact&quot; value=&quot;email&quot;&gt; Email &lt;/p&gt;
&lt;hr&gt;
&lt;p&gt;Use the space below for additional questions &amp; comments:&lt;/p&gt;
&lt;p&gt;&lt;textarea COLS=&quot;30&quot; NAME=&quot;other_info0&quot; id=&quot;ff_elem205&quot; style=&quot;height: 63; width: 612&quot; rows=&quot;3&quot;&gt;&lt;/textarea&gt;&lt;/p&gt;
&lt;p&gt;&lt;input type=&quot;submit&quot; value=&quot;Send to Boozman-Hof&quot; name=&quot;Submit&quot; style=&quot;font-style: italic; font-weight: bold&quot;&gt;       
&lt;input type=&quot;reset&quot; value=&quot;Reset (cancel form)&quot; name=&quot;reset&quot; style=&quot;font-size: 8pt; font-style: oblique&quot;&gt;&lt;/p&gt;
&lt;hr&gt;

Post edited by: laurel, at: 2007/08/31 08:56 Edited for clarity, removed Mso classes and <form> tags.<br><br>Post edited by: GreyHead, at: 2007/08/31 10:57

Report to moderator Logged

Logged

Laurel Fitzhugh
http://www.dittany.com

The administrator has disabled public write access.

#2015

GreyHead (Admin)

Admin

Posts: 2801

Re:Optical Contact / Request Information form 10 Months, 1 Week ago	Karma: 59
Hi Laurel, Nice form, thank you. Bob PS In context here.<br><br>Post edited by: GreyHead, at: 2007/08/31 11:09

Report to moderator Logged

Logged

Bob Janes
info at greyhead.net
ChronoForms Support If you like ChronoForms please vote or post a review at Joomla.org

The administrator has disabled public write access.

#2025

admin (Admin)

Admin

Posts: 1570

Re:Optical Contact / Request Information form 10 Months, 1 Week ago	Karma: 22
Thank you very much Laurel!! Sincerely, Max

Report to moderator Logged

Logged

ChronoForms Developer Thanks for using ChronoForms.
If you have any problems with ChronoForms please tell us.
If you like ChronoForms please post a review at Joomla.org

The administrator has disabled public write access.

#3243

adodis tech (User)

Fresh Boarder

Posts: 1

Re:Optical Contact / Request Information form 8 Months, 1 Week ago	Karma: 0
hi very nice form, code also available so one more thank u thanks http://www.joomla-web-designer.com/ http://www.joomla-web-developer.com/

Report to moderator Logged

Logged

The administrator has disabled public write access.

Forum List

ChronoForms Forums

Share your forms with others

get the latest posts directly to your desktop

equalheight If you have any questions you can post to our forums and we will be glad to help ASAP

Re:chrono form and joomfish
raimond 04-07-08 16:39
How to set up a multilanguage version
werwi007 04-07-08 16:35
Re:validate-one-required not working for me
Bullfn33 04-07-08 16:18
Re:multiple fields displayed in Email S...
tonimarie 04-07-08 14:25
Re:Show data not working?
jpc0480 04-07-08 13:59
Re:error message with image verification
GreyHead 04-07-08 12:16
Re:error message with image verification
contamine 04-07-08 12:09
Re:Database Table
GreyHead 04-07-08 11:18
Re:Error with form in article using cb ...
GreyHead 04-07-08 11:15
Re:Can i pass the form data to another form
GreyHead 04-07-08 10:18
Re:Database Table
losmoses 04-07-08 10:09
Re:Send registration to 2 email addresses?
trunky 04-07-08 09:56
Re:Database Table
GreyHead 04-07-08 09:36
Re:Send registration to 2 email addresses?
GreyHead 04-07-08 09:35
Re:Send registration to 2 email addresses?
trunky 04-07-08 09:30

Members Login

2CheckOut.com Inc. (Ohio, USA) is an authorized retailer for
goods and services provided by ChronoEngine.com

ChronoForms License

equalheight To be able to continue working at this component we decided to get a small profit out of it but at the same time don't force everybody to pay in order to use this great component.

From version 1.5 and up a link at the bottom of everyform created will be placed, saying "joomla professional work", the link will be to us here htttp://www.chronoengine.com, its illegal to remove this link from the source code unless you have a license,

so the license is very simply for the same ChronoForms component without a link, thats all!

This License is for 5 different websites ONLY.

However, in order to allow everybody to still use the component and even get out of this, the link is inside a div with class : chronoform , use this to hide the link by using different colors or whatever if you really can't pay, but of course the link is still exists at your page source.

The license is ONLY 25$ can be bought here :

Thank you!

ChronoEngine.com Team

HEADER

Members Login

ChronoForms License