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<?php
// if the from is loaded from WordPress form loader plugin,
// the phpfmg_display_form() will be called by the loader
if( !defined('FormmailMakerFormLoader') ){
# This block must be placed at the very top of page.
# --------------------------------------------------
require_once( dirname(__FILE__).'/form.lib.php' );
phpfmg_display_form();
# --------------------------------------------------
};
function phpfmg_form( $sErr = false ){
$style=" class='form_text' ";
?>
<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN">
<HTML>
<HEAD>
<META http-equiv="Content-Type" CONTENT="text/html; charset=iso-8859-1">
<LINK HREF="../styles.css" TYPE="text/css" REL="STYLESHEET">
<META CONTENT="MSHTML 6.00.2712.300" NAME="GENERATOR">
<TITLE>Customer Support</TITLE>
</HEAD>
<body bgcolor="#FFFFFF" leftmargin="0" topmargin="0" marginwidth="0" marginheight="0">
<table width="100%" border="0" cellspacing="0" cellpadding="0" height="100%">
<tr valign="top">
<td height="65">
<table width="100%" border="0" cellspacing="0" cellpadding="0">
<tr valign="top">
<td height="71" width="79%"><a href="index.htm"><img src="images/InteriorLogo.gif" width="199" height="77" border="0"></a><img src="images/InteriorSpacer.gif" width="341" height="77"></td>
<td height="71" width="21%">
<div align="right"><img src="images/InteriorContact.gif" width="210" height="77" usemap="#MapMap" border="0"><map name="MapMap"><area shape="rect" coords="1,45,83,64" href="contactus.htm"><area shape="rect" coords="103,44,168,64" href="sitemap.htm"></map></div>
</td>
</tr>
</table>
</td>
</tr>
<tr bgcolor="3399CC" valign="top">
<td height="35">
<table width="750" border="0" cellspacing="0" cellpadding="0">
<tr valign="middle">
<td class="box2" height="35"> <a href="surgical.htm">Medical
Products</a> | <A HREF="supform.php">Parts Info</a> | <a href="manuals.htm">Manuals</a> | <a href="whatsnew.htm">What's
New</a> | <A HREF="supform.php">Customer Service</a> | <a href="aboutus.htm">About
Us</a> </td>
</tr>
</table>
</td>
</tr>
<tr align="left" valign="top">
<td height="100%">
<table width="100%" border="0" cellspacing="0" cellpadding="0" height="100%">
<tr>
<td width="156" height="262" valign="top" background="images/InteriorSideNAv.gif"><img src="images/InteriorSideNAv.gif" width="179" height="39"><br>
</td>
<td width="846" height="262" valign="top">
<table border="0" cellspacing="0" cellpadding="0" width="100%">
<tr valign="middle">
<td class="headers" height="51" width="16"> </td>
<td class="headers" height="51" width="560" valign="bottom">
<p>Customer Service:</p>
</td>
</tr>
<tr valign="top">
<td height="42" class="subheaders" width="16"> </td>
<td height="42" class="text" width="560" valign="top">
<div align=left>
<p>Highland Labs is committed to providing exceptional support
for our customers. Please use the form below to let us know
how we can help you. After filling in pertinent information,
click the Submit button and we will contact you with the
requested information as soon as possible.</p>
</div>
<div align=left>
<p>You may also reach us at:</p>
</div>
<div align=left>
<p><strong>Highland Labs, Inc.<br>
163 Woodland Street<br>
Holliston, MA 01746</strong> </p>
<p> <b>Telephone:</b> (508) 429-2918<br>
<b>Fax:</b> (508) 429-6283<br>
<b>E-mail:</b> <a href="mailto:[email protected]">[email protected]</a></p>
<p><a href="CreditCardForm.pdf" target="_blank">Click here
for the Credit Card Form</a></p>
<p><a href="CreditApplication.pdf" target="_blank">Click here
for the Credit Application Form</a></p>
<div id='frmFormMailContainer'>
<form name="frmFormMail" id="frmFormMail" target="submitToFrame" action='<?php echo PHPFMG_ADMIN_URL . '' ; ?>' method='post' enctype='multipart/form-data' onsubmit='return fmgHandler.onSubmit(this);'>
<input type='hidden' name='formmail_submit' value='Y'>
<input type='hidden' name='mod' value='ajax'>
<input type='hidden' name='func' value='submit'>
<ol class='phpfmg_form' >
<li class='field_block' id='field_0_div'><div class='col_label'>
<label class='form_field'>First Name</label> <label class='form_required' >*</label> </div>
<div class='col_field'>
<input type="text" name="field_0" id="field_0" value="<?php phpfmg_hsc("field_0", ""); ?>" class='text_box' maxlength="50" size="25">
<div id='field_0_tip' class='instruction'></div>
</div>
</li>
<li class='field_block' id='field_1_div'><div class='col_label'>
<label class='form_field'>Last Name</label> <label class='form_required' >*</label> </div>
<div class='col_field'>
<input type="text" name="field_1" id="field_1" value="<?php phpfmg_hsc("field_1", ""); ?>" class='text_box' maxlength="75" size="25">
<div id='field_1_tip' class='instruction'></div>
</div>
</li>
<li class='field_block' id='field_2_div'><div class='col_label'>
<label class='form_field'>Title</label> <label class='form_required' > </label> </div>
<div class='col_field'>
<input type="text" name="field_2" id="field_2" value="<?php phpfmg_hsc("field_2", ""); ?>" class='text_box' maxlength="50" size="25">
<div id='field_2_tip' class='instruction'></div>
</div>
</li>
<li class='field_block' id='field_3_div'><div class='col_label'>
<label class='form_field'>Company</label> <label class='form_required' > </label> </div>
<div class='col_field'>
<input type="text" name="field_3" id="field_3" value="<?php phpfmg_hsc("field_3", ""); ?>" class='text_box' maxlength="75" size="25">
<div id='field_3_tip' class='instruction'></div>
</div>
</li>
<li class='field_block' id='field_4_div'><div class='col_label'>
<label class='form_field'>Address</label> <label class='form_required' > </label> </div>
<div class='col_field'>
<input type="text" name="field_4" id="field_4" value="<?php phpfmg_hsc("field_4", ""); ?>" class='text_box' maxlength="75" size="25">
<div id='field_4_tip' class='instruction'></div>
</div>
</li>
<li class='field_block' id='field_5_div'><div class='col_label'>
<label class='form_field'>City</label> <label class='form_required' > </label> </div>
<div class='col_field'>
<input type="text" name="field_5" id="field_5" value="<?php phpfmg_hsc("field_5", ""); ?>" class='text_box' maxlength="50" size="25">
<div id='field_5_tip' class='instruction'></div>
</div>
</li>
<li class='field_block' id='field_6_div'><div class='col_label'>
<label class='form_field'>State</label> <label class='form_required' > </label> </div>
<div class='col_field'>
<input type="text" name="field_6" id="field_6" value="<?php phpfmg_hsc("field_6", ""); ?>" class='text_box' maxlength="2" size="4">
<div id='field_6_tip' class='instruction'></div>
</div>
</li>
<li class='field_block' id='field_7_div'><div class='col_label'>
<label class='form_field'>Zip</label> <label class='form_required' > </label> </div>
<div class='col_field'>
<input type="text" name="field_7" id="field_7" value="<?php phpfmg_hsc("field_7", ""); ?>" class='text_box' maxlength="10" size="10">
<div id='field_7_tip' class='instruction'></div>
</div>
</li>
<li class='field_block' id='field_8_div'><div class='col_label'>
<label class='form_field'>Telephone</label> <label class='form_required' > </label> </div>
<div class='col_field'>
<input type="text" name="field_8" id="field_8" value="<?php phpfmg_hsc("field_8", ""); ?>" class='text_box' maxlength="14" size="14">
<div id='field_8_tip' class='instruction'></div>
</div>
</li>
<li class='field_block' id='field_9_div'><div class='col_label'>
<label class='form_field'>Fax</label> <label class='form_required' > </label> </div>
<div class='col_field'>
<input type="text" name="field_9" id="field_9" value="<?php phpfmg_hsc("field_9", ""); ?>" class='text_box' maxlength="14" size="14">
<div id='field_9_tip' class='instruction'></div>
</div>
</li>
<li class='field_block' id='field_10_div'><div class='col_label'>
<label class='form_field'>Email</label> <label class='form_required' >*</label> </div>
<div class='col_field'>
<input type="text" name="field_10" id="field_10" value="<?php phpfmg_hsc("field_10", ""); ?>" class='text_box' maxlength="75" size="25">
<div id='field_10_tip' class='instruction'></div>
</div>
</li>
<li class='field_block' id='field_11_div'><div class='col_label'>
<label class='form_field'>Comments</label> <label class='form_required' > </label> </div>
<div class='col_field'>
<textarea name="field_11" id="field_11" rows=4 cols=25 class='text_area'><?php phpfmg_hsc("field_11"); ?></textarea>
<div id='field_11_tip' class='instruction'></div>
</div>
</li>
<li>
<div class='col_label'> </div>
<div class='form_submit_block col_field'>
<input type='submit' value='Submit' class='form_button'>
<div id='err_required' class="form_error" style='display:none;'>
<label class='form_error_title'>Please check the required fields</label>
</div>
<span id='phpfmg_processing' style='display:none;'>
<img id='phpfmg_processing_gif' src='<?php echo PHPFMG_ADMIN_URL . '?mod=image&func=processing' ;?>' border=0 alt='Processing...'> <label id='phpfmg_processing_dots'></label>
</span>
</div>
</li>
</ol>
</form>
<iframe name="submitToFrame" id="submitToFrame" src="javascript:false" style="position:absolute;top:-10000px;left:-10000px;" /></iframe>
</div>
<!-- end of form container -->
<!-- [Your confirmation message goes here] -->
<div id='thank_you_msg' style='display:none;'>
Your form has been sent. Thank you!
</div>
<?php
phpfmg_javascript($sErr);
}
# end of form
function phpfmg_form_css(){
$formOnly = isset($GLOBALS['formOnly']) && true === $GLOBALS['formOnly'];
?>
<style type='text/css'>
<?php
if( !$formOnly ){
echo"
body{
margin-left: 18px;
margin-top: 18px;
}
body{
font-family : Verdana, Arial, Helvetica, sans-serif;
font-size : 13px;
color : #474747;
background-color: transparent;
}
select, option{
font-size:13px;
}
";
}; // if
?>
ol.phpfmg_form{
list-style-type:none;
padding:0px;
margin:0px;
}
ol.phpfmg_form input, ol.phpfmg_form textarea, ol.phpfmg_form select{
border: 1px solid #ccc;
-moz-border-radius: 3px;
-webkit-border-radius: 3px;
border-radius: 3px;
}
ol.phpfmg_form li{
margin-bottom:5px;
clear:both;
display:block;
overflow:hidden;
width: 100%
}
.form_field, .form_required{
font-weight : bold;
}
.form_required{
color:red;
margin-right:8px;
}
.field_block_over{
}
.form_submit_block{
padding-top: 3px;
}
.text_box,.text_select {
height: 32px;
}
.text_box, .text_area, .text_select {
min-width:160px;
max-width:300px;
width: 100%;
margin-bottom: 10px;
}
.text_area{
height:80px;
}
.form_error_title{
font-weight: bold;
color: red;
}
.form_error{
background-color: #F4F6E5;
border: 1px dashed #ff0000;
padding: 10px;
margin-bottom: 10px;
}
.form_error_highlight{
background-color: #F4F6E5;
border-bottom: 1px dashed #ff0000;
}
div.instruction_error{
color: red;
font-weight:bold;
}
hr.sectionbreak{
height:1px;
color: #ccc;
}
#one_entry_msg{
background-color: #F4F6E5;
border: 1px dashed #ff0000;
padding: 10px;
margin-bottom: 10px;
}
#frmFormMailContainer input[type="submit"]{
padding: 10px 25px;
font-weight: bold;
margin-bottom: 10px;
background-color: #FAFBFC;
}
#frmFormMailContainer input[type="submit"]:hover{
background-color: #E4F0F8;
}
<?php phpfmg_text_align();?>
</style>
<?php
}
# end of css
# By: formmail-maker.com
?>
<p> </p>
</div>
</td>
</tr>
<tr valign="top">
<td width="16"> </td>
<td width="560"> </td>
</tr>
</table>
</td>
</tr>
<tr>
<td width="156" height="22" valign="top" background="images/InteriorSideNAv.gif"> </td>
<td width="846" height="22" valign="top">
<table width="100%" border="0" cellspacing="0" cellpadding="0">
<tr>
<td height="35">
<div align="center">
<table width="80%" border="0" cellspacing="0" cellpadding="0" height="25">
<tr>
<td class="footer">
<div align="center"><a href="surgical.htm" class="footer">Medical
Products</a></div>
</td>
<td class="footer"> <div align="center"><a href="supform.php" class="footer">Parts
Info</a></div></td>
<td class="footer">
<div align="center"><a href="manuals.htm" class="footer">Manuals</a></div>
</td>
<td class="footer"> <div align="center"><a href="whatsnew.htm" class="footer">What's
New</a></div></td>
<td class="footer"> <div align="center"><a href="supform.php" class="footer">Customer
Service</a></div></td>
<td class="footer">
<div align="center"><a href="aboutus.htm" class="footer">About
Us</a></div>
</td>
</tr>
</table>
<font face="Verdana, Arial, Helvetica, sans-serif" size="1"></font></div>
</td>
</tr>
</table>
</td>
</tr>
</table>
</td>
</tr>
</table>
</body>
</html>