<%args> $control=>'mailForm' $Email => 'kelly@ccs-corporate.com' <%shared> my $IEmail; my %IARGS; <%init> $IEmail = $Email; %IARGS = %ARGS; <&$control&> <%def mailForm>

Schedule an Appointment

After you have filled out this form, please review your information. If everything is correct, please click the submit button below.  We will contact you within 24 hours letting you know what appointments we have available during the week you have selected.

Thank you for your cooperation.

Please provide the following contact information:

	First Name:	Last Name:
	Mailing Address:	City:
	State/Province:	Zip/Postal Code:
	Date of Birth:	E-mail Address:
	Home Phone:	Cell Phone:
	Work Phone:	Fax Number:
	Please Contact me via:	Preferred Appointment Day:
	Choose One Home Phone Cell Phone Work Phone Fax	Choose One Monday Tuesday Wednesday Thursday Friday
	Preferred Appointment Time:	Appointment Priority:
	Choose One Early Morning Late Morning Early Afternoon Late Afternoon	Choose One High Medium Low
	Reason for Visit:

<%def email> <%init> use MIME::Lite; my $email = MIME::Lite->new( To => 'prevention.specialist@verizon.net', Subject => 'Contact Us', From => '"Appointment Request" ', Type => 'TEXT', Data => " First Name: $IARGS{fname} Last Name: $IARGS{lname} Address: $IARGS{address} City: $IARGS{city} State: $IARGS{state} Zip: $IARGS{zip} Birthday: $IARGS{bday} Email: $IARGS{email} Home Phone: $IARGS{hphone} Cell Phone: $IARGS{cphone} Work Phone: $IARGS{wphone} Fax: $IARGS{fax} How to Contact: $IARGS{how} What Day: $IARGS{wday} What Time: $IARGS{wtime} Appointment Priority: $IARGS{priority} Comments: $IARGS{comments}" ); $email->send; my $callPage=$IARGS{'callPage'}; $m->redirect("?control=done"); <%def done> <%flags> inherit=>undef

Thank you, your information has been sent.

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