I built a website for the pharmacy I work at (www.xyz.com) and wanted to have a form where people could request Rx refills that would be sent to our email address ([email protected]). I used a free PHP formmail code I found online, but I cannot get it to work (when I fill out the form and click send I do get an email, but it is blank. I will include my PHP and HTML. Thanks for any help you can give!!!
Justin
This is the PHP:
// for ultimate security, use this instead of using the form
$recipient = "[email protected]"; // [email protected]
// bcc emails (separate multiples with commas (,))
$bcc = “”;
// referers… domains/ips that you will allow forms to
// reside on.
$referers = array (‘xyz.com’,‘http://www.xyz.com’,‘216.69.185.1’);
// banned emails, these will be email addresses of people
// who are blocked from using the script (requested)
$banlist = array (’*@somedomain.com’, ‘[email protected]’, ‘[email protected]’);
// field / value seperator
define(“SEPARATOR”, ($separator)?$separator:": ");
// content newline
define(“NEWLINE”, ($newline)?$newline:"\n");
// formmail version (for debugging mostly)
define(“VERSION”, “5.0”);
// our mighty error function…
function print_error($reason,$type = 0) {
build_body($title, $bgcolor, $text_color, $link_color, $vlink_color, $alink_color, $style_sheet);
// for missing required data
if ($type == “missing”) {
if ($missing_field_redirect) {
header(“Location: $missing_field_redirect?error=$reason”);
exit;
} else {
?>
The form was not submitted for the following reasons:
- <?
echo $reason."\n";
?>
Please use your browser’s back button to return to the form and try again.<?
}
} else { // every other error
?>
The form was not submitted because of the following reasons:
<?
}
echo “
\n”;
echo “This form is powered by <a href=“http://www.dtheatre.com/scripts/”>Jack’s Formmail.php “.VERSION.”\n\n”;
exit;
}
// function to check the banlist
// suggested by a whole lot of people… Thanks
function check_banlist($banlist, $email) {
if (count($banlist)) {
$allow = true;
foreach($banlist as $banned) {
$temp = explode("@", $banned);
if ($temp[0] == “*”) {
$temp2 = explode("@", $email);
if (trim(strtolower($temp2[1])) == trim(strtolower($temp[1])))
$allow = false;
} else {
if (trim(strtolower($email)) == trim(strtolower($banned)))
$allow = false;
}
}
}
if (!$allow) {
print_error(“You are using from a banned email address.”);
}
}
// function to check the referer for security reasons.
// contributed by some one who’s name got lost… Thanks
// goes out to him any way.
function check_referer($referers) {
if (count($referers)) {
$found = false;
$temp = explode("/",getenv("HTTP_REFERER"));
$referer = $temp[2];
if ($referer=="") {$referer = $_SERVER['HTTP_REFERER'];
list($remove,$stuff)=split('//',$referer,2);
list($home,$stuff)=split('/',$stuff,2);
$referer = $home;
}
for ($x=0; $x < count($referers); $x++) {
if (eregi ($referers[$x], $referer)) {
$found = true;
}
}
if ($referer =="")
$found = false;
if (!$found){
print_error("You are coming from an <b>unauthorized domain.</b>");
error_log("[FormMail.php] Illegal Referer. (".getenv("HTTP_REFERER").")", 0);
}
return $found;
} else {
return true; // not a good idea, if empty, it will allow it.
}
}
if ($referers)
check_referer($referers);
if ($banlist)
check_banlist($banlist, $email);
// This function takes the sorts, excludes certain keys and
// makes a pretty content string.
function parse_form($array, $sort = “”) {
// build reserved keyword array
$reserved_keys[] = “MAX_FILE_SIZE”;
$reserved_keys[] = “required”;
$reserved_keys[] = “redirect”;
$reserved_keys[] = “require”;
$reserved_keys[] = “path_to_file”;
$reserved_keys[] = “recipient”;
$reserved_keys[] = “subject”;
$reserved_keys[] = “sort”;
$reserved_keys[] = “style_sheet”;
$reserved_keys[] = “bgcolor”;
$reserved_keys[] = “text_color”;
$reserved_keys[] = “link_color”;
$reserved_keys[] = “vlink_color”;
$reserved_keys[] = “alink_color”;
$reserved_keys[] = “title”;
$reserved_keys[] = “missing_fields_redirect”;
$reserved_keys[] = “env_report”;
$reserved_keys[] = “submit”;
if (count($array)) {
if (is_array($sort)) {
foreach ($sort as $field) {
$reserved_violation = 0;
for ($ri=0; $ri<count($reserved_keys); $ri++)
if ($array[$field] == $reserved_keys[$ri]) $reserved_violation = 1;
if ($reserved_violation != 1) {
if (is_array($array[$field])) {
for ($z=0;$z<count($array[$field]);$z++)
$content .= $field.SEPARATOR.$array[$field][$z].NEWLINE;
} else
$content .= $field.SEPARATOR.$array[$field].NEWLINE;
}
}
}
while (list($key, $val) = each($array)) {
$reserved_violation = 0;
for ($ri=0; $ri<count($reserved_keys); $ri++)
if ($key == $reserved_keys[$ri]) $reserved_violation = 1;
for ($ri=0; $ri<count($sort); $ri++)
if ($key == $sort[$ri]) $reserved_violation = 1;
// prepare content
if ($reserved_violation != 1) {
if (is_array($val)) {
for ($z=0;$z<count($val);$z++)
$content .= $key.SEPARATOR.$val[$z].NEWLINE;
} else
$content .= $key.SEPARATOR.$val.NEWLINE;
}
}
}
return $content;
}
// mail the content we figure out in the following steps
function mail_it($content, $subject, $email, $recipient) {
global $attachment_chunk, $attachment_name, $attachment_type, $attachment_sent, $bcc;
$ob = “----=_OuterBoundary_000”;
$ib = “----=_InnerBoundery_001”;
$headers = “MIME-Version: 1.0\r\n”;
$headers .= “From: “.$email.”\n”;
$headers .= “To: “.$recipient.”\n”;
$headers .= “Reply-To: “.$email.”\n”;
if ($bcc) $headers .= “Bcc: “.$bcc.”\n”;
$headers .= “X-Priority: 1\n”;
$headers .= “X-Mailer: DT Formmail”.VERSION."\n";
$headers .= “Content-Type: multipart/mixed;\n\tboundary=”".$ob.""\n";
$message = “This is a multi-part message in MIME format.\n”;
$message .= “\n–”.$ob."\n";
$message .= “Content-Type: multipart/alternative;\n\tboundary=”".$ib.""\n\n";
$message .= “\n–”.$ib."\n";
$message .= “Content-Type: text/plain;\n\tcharset=“iso-8859-1”\n”;
$message .= “Content-Transfer-Encoding: quoted-printable\n\n”;
$message .= $content."\n\n";
$message .= “\n–”.$ib."–\n";
if ($attachment_name && !$attachment_sent) {
$message .= “\n–”.$ob."\n";
$message .= “Content-Type: $attachment_type;\n\tname=”".$attachment_name.""\n";
$message .= “Content-Transfer-Encoding: base64\n”;
$message .= “Content-Disposition: attachment;\n\tfilename=”".$attachment_name.""\n\n";
$message .= $attachment_chunk;
$message .= “\n\n”;
$attachment_sent = 1;
}
$message .= “\n–”.$ob."–\n";
mail($recipient, $subject, $message, $headers);
}
// take in the body building arguments and build the body tag for page display
function build_body($title, $bgcolor, $text_color, $link_color, $vlink_color, $alink_color, $style_sheet) {
if ($style_sheet)
echo “<LINK rel=STYLESHEET href=”$style_sheet" Type=“text/css”>\n";
if ($title)
echo “$title\n”;
if (!$bgcolor)
$bgcolor = “#FFFFFF”;
if (!$text_color)
$text_color = “#000000”;
if (!$link_color)
$link_color = “#0000FF”;
if (!$vlink_color)
$vlink_color = “#FF0000”;
if (!$alink_color)
$alink_color = “#000088”;
if ($background)
$background = “background=”$background"";
echo “<body bgcolor=”$bgcolor" text="$text_color" link="$link_color" vlink="$vlink_color" alink="$alink_color" $background>\n\n";
}
// check for a recipient email address and check the validity of it
// Thanks to Bradley miller ([email protected]) for pointing
// out the need for multiple recipient checking and providing the code.
$recipient_in = split(’,’,$recipient);
for ($i=0;$i<count($recipient_in);$i++) {
$recipient_to_test = trim($recipient_in[$i]);
if (!eregi("^[_\.0-9a-z-]+@([0-9a-z][0-9a-z-]+\.)+[a-z]{2,6}$", $recipient_to_test)) {
print_error(“I NEED VALID RECIPIENT EMAIL ADDRESS ($recipient_to_test) TO CONTINUE”);
}
}
// This is because I originally had it require but too many people
// were used to Matt’s Formmail.pl which used required instead.
if ($required)
$require = $required;
// handle the required fields
if ($require) {
// seperate at the commas
$require = ereg_replace( " +", “”, $require);
$required = split(",",$require);
for ($i=0;$i<count($required);$i++) {
$string = trim($required[$i]);
// check if they exsist
if((!(${$string})) || (!(${$string}))) {
// if the missing_fields_redirect option is on: redirect them
if ($missing_fields_redirect) {
header (“Location: $missing_fields_redirect”);
exit;
}
$require;
$missing_field_list .= “Missing: $required[$i]
\n”;
}
}
// send error to our mighty error function
if ($missing_field_list)
print_error($missing_field_list,“missing”);
}
// check the email fields for validity
if (($email) || ($EMAIL)) {
$email = trim($email);
if ($EMAIL) $email = trim($EMAIL);
if (!eregi("^[_.0-9a-z-]+@([0-9a-z][0-9a-z-]+.)+[a-z]{2,6}$", $email))
print_error(“your email address is invalid”);
$EMAIL = $email;
}
// check zipcodes for validity
if (($ZIP_CODE) || ($zip_code)) {
$zip_code = trim($zip_code);
if ($ZIP_CODE) $zip_code = trim($ZIP_CODE);
if (!ereg("(^[0-9]{5})-([0-9]{4}$)", trim($zip_code)) && (!ereg("^[a-zA-Z][0-9][a-zA-Z][[:space:]][0-9][a-zA-Z][0-9]$", trim($zip_code))) && (!ereg("(^[0-9]{5})", trim($zip_code))))
print_error(“your zip/postal code is invalid”);
}
// check phone for validity
if (($PHONE_NO) || ($phone_no)) {
$phone_no = trim($phone_no);
if ($PHONE_NO) $phone_no = trim($PHONE_NO);
if (!ereg("(^(.)[0-9]{3})(.)([0-9]{3})(.*)([0-9]{4}$)", $phone_no))
print_error(“your phone number is invalid”);
}
// check phone for validity
if (($FAX_NO) || ($fax_no)) {
$fax_no = trim($fax_no);
if ($FAX_NO) $fax_no = trim($FAX_NO);
if (!ereg("(^(.)[0-9]{3})(.)([0-9]{3})(.*)([0-9]{4}$)", $fax_no))
print_error(“your fax number is invalid”);
}
// sort alphabetic or prepare an order
if ($sort == “alphabetic”) {
uksort($HTTP_POST_VARS, “strnatcasecmp”);
} elseif ((ereg(’^order:.,.’, $sort)) && ($list = explode(’,’, ereg_replace(’^order:’, ‘’, $sort)))) {
$sort = $list;
}
// prepare the content
$content = parse_form($HTTP_POST_VARS, $sort);
// check for an attachment if there is a file upload it
if ($attachment_name) {
if ($attachment_size > 0) {
if (!$attachment_type) $attachment_type = “application/unknown”;
$content .= “Attached File: “.$attachment_name.”\n”;
$fp = fopen($attachment, “r”);
$attachment_chunk = fread($fp, filesize($attachment));
$attachment_chunk = base64_encode($attachment_chunk);
$attachment_chunk = chunk_split($attachment_chunk);
}
}
// check for a file if there is a file upload it
if ($file_name) {
if ($file_size > 0) {
if (!ereg("/$", $path_to_file))
$path_to_file = $path_to_file."/";
$location = $path_to_file.$file_name;
if (file_exists($path_to_file.$file_name))
$location = $path_to_file.rand(1000,3000).".".$file_name;
copy($file,$location);
unlink($file);
$content .= “Uploaded File: “.$location.”\n”;
}
}
// second file (see manual for instructions on how to add more.)
if ($file2_name) {
if ($file_size > 0) {
if (!ereg("/$", $path_to_file))
$path_to_file = $path_to_file."/";
$location = $path_to_file.$file2_name;
if (file_exists($path_to_file.$file2_name))
$location = $path_to_file.rand(1000,3000).".".$file2_name;
copy($file2,$location);
unlink($file2);
$content .= “Uploaded File: “.$location.”\n”;
}
}
// if the env_report option is on: get eviromental variables
if ($env_report) {
$env_report = ereg_replace( " +", “”, $env_report);
$env_reports = split(",",$env_report);
$content .= “\n------ eviromental variables ------\n”;
for ($i=0;$i<count($env_reports);$i++) {
$string = trim($env_reports[$i]);
if ($env_reports[$i] == “REMOTE_HOST”)
$content .= “REMOTE HOST: “.$REMOTE_HOST.”\n”;
if ($env_reports[$i] == “REMOTE_USER”)
$content .= “REMOTE USER: “. $REMOTE_USER.”\n”;
if ($env_reports[$i] == “REMOTE_ADDR”)
$content .= “REMOTE ADDR: “. $REMOTE_ADDR.”\n”;
if ($env_reports[$i] == “HTTP_USER_AGENT”)
$content .= “BROWSER: “. $HTTP_USER_AGENT.”\n”;
}
}
// send it off
mail_it(stripslashes($content), ($subject)?stripslashes($subject):“Form Submission”, $email, $recipient);
if (file_exists($ar_file)) {
$fd = fopen($ar_file, “rb”);
$ar_message = fread($fd, filesize($ar_file));
fclose($fd);
mail_it($ar_message, ($ar_subject)?stripslashes($ar_subject):“RE: Form Submission”, ($ar_from)?$ar_from:$recipient, $email);
}
// if the redirect option is set: redirect them
if ($redirect) {
header(“Location: $redirect”);
exit;
} else {
echo “Thank you for your submission\n”;
echo “
\n”;
echo “\n\n”;
exit;
}
This is the HTML:
Prescription Refill Request #form_container { background: #e2eff3;font-family: arial; color: #144c5f; font-size: 13px; font-weight:bold;letter-spacing: 0.0005em; line-height: 1.15em; overflow:auto; margin-top:0px;} body { background:; color: #000; font: normal normal 12px Verdana, Geneva, Arial, Helvetica, sans-serif; margin: 0px; padding: 0} table, td, a { color: #000; font: normal normal 12px Verdana, Geneva, Arial, Helvetica, sans-serif} div.tableContainer { clear: both; border:; height: 303px; overflow: auto; width: 640px} html>body div.tableContainer { overflow: hidden; width: 640px} div.tableContainer table { float: left; width: 620px} html>body div.tableContainer table { width: 640px} html>body tbody.scrollContent { display: block; height: 303px; overflow-x: hidden; overflow-y: auto; width: 100%} tbody.scrollContent tr.alternateRow td { background: blue; border-bottom: none; border-left: none; border-right: 1px solid #CCC; border-top: 1px solid #DDD; padding: 2px 3px 3px 4px} html>body tbody.scrollContent td {width: 639px} html>body tbody.scrollContent td {width: 639px}
Prescription Refill RequestBeat the rush, and send us a list of your prescriptions to be filled in advance. Check if you’d like to be notified when your Rx(s) have been filled. |
</body>