"; $mailtext.="Last Name: ".safe($_POST["lname"])."
"; if (safe($_POST["phone2"])!='' and safe($_POST["phone3"])!='') $mailtext.="Phone: ".((safe($_POST["phone1"])!='')?"(".safe($_POST["phone1"]).") ":'').safe($_POST["phone2"])."-".safe($_POST["phone3"])."
"; $mailtext.="E-mail Address: ".safe($_POST["email"])."
"; $mailtext.="City: ".safe($_POST["city"])."
"; $mailtext.="State: ".safe($_POST["state"])."
"; $mailtext.="Primary insurance provider: ".safe($_POST["insurance"])."
"; $mailtext.="Best time to contact: ".safe($_POST["besttime"])."
"; $mailtext.="Comments: ".safe($_POST["comments"])."
"; //build headers $headers = "MIME-Version: 1.0\r\n"; $headers .= "Content-type: text/html; charset=iso-8859-1\r\n"; $headers .= "From: \"www.powerchairs.com\" <".$adminemail1.">\r\n"; $headers .= "Date: ".date("r")."\r\n"; mail($adminemail1,"Request Free Information",$mailtext,$headers); mail($adminemail2,"Request Free Information",$mailtext,$headers); ?>
Thank you for your request!
First NameLast NamePhone
- -

Power Chairs is one of the leading providers of electric wheelchairs in the United States. As a qualified Medicare provider, we process all of the necessary paperwork to help you get a motorized wheelchair at little or no cost to you through your insurance provider. *

* The actual cost of medical equipment depends on individual insurance benefits and medical condition.

** By submitting this form, you agree to allow JaspanMedical to use the supplied contact information to contact about medical equipment.

$mailtext"; ?>