<% Dim strMail Dim chkProductInfo,chkProductDemo,chkEmail,chkPhone,ProductInterest,Description,Month,Year,FirstName Dim LastName,Email,JobTitle,JobTitleOthers,Facility,FacilityOthers,Company,Address,City,State,Country Dim ZIP,Phone,Fax,HearFrom,ModMRI,ModCT,ModPET,ModUS,ModNM,ModCR,ModOthers,AnnMRI,AnnCT,AnnUS,AnnNM,AnnCR,AnnOthers if (Request("Submit") <> "") then if ((Request("chkProductInfo") <> "") or (Request("chkProductDemo") <> "")) then strMail = "Please Send Me: " if (Request("chkProductInfo") <> "") then strMail = strMail & Request("chkProductInfo") end if if (Request("chkProductDemo") <> "") then if (Request("chkProductInfo") <> "") then strMail = strMail & " and " end if strMail = strMail & Request("chkProductDemo") end if end if if (( Request("chkEmail") <> "") or (Request("chkPhone") <> "")) then strMail = strMail & vbCrlf & "Please contact us by: " if ( Request("chkEmail") <> "") then strMail = strMail & Request("chkEmail") end if if (Request("chkPhone") <> "") then if ( Request("chkEmail") <> "") then strMail = strMail & " and " end if strMail = strMail & Request("chkPhone") end if end if strMail = strMail & vbCrlf & "Product Interest: " & vbCrlf strMail = strMail & Request("ProductInterest") if (Request("Description") <> "") then strMail = strMail & "Description of unique and / or specific requirements: " & vbCrlf strMail = strMail & Request("Description") end if strMail = strMail & vbCrlf & "Planned PACS-RIS purchase / implementation date: " & Request("Month") & "/" & Request("Year") strMail = strMail & vbCrlf & "Name: " & Request("LastName") & ", " & Request("FirstName") strMail = strMail & vbCrlf & "Email: " & Request("Email") strMail = strMail & vbCrlf & "Title/Position: " & Request("JobTitle") if (Request("JobTitleOthers") <> "") then strMail = strMail & ", " & Request("JobTitleOthers") end if strMail = strMail & vbCrlf & "Facility: " & Request("Facility") if (Request("FacilityOthers") <> "") then strMail = strMail & ", " & Request("FacilityOthers") end if strMail = strMail & vbCrlf & "Company: " & Request("Company") strMail = strMail & vbCrlf & "Address: " & Request("Address") strMail = strMail & vbCrlf & "City: " & Request("City") strMail = strMail & vbCrlf & "State: " & Request("State") strMail = strMail & vbCrlf & "Country: " & Request("Country") strMail = strMail & vbCrlf & "ZIP: " & Request("ZIP") strMail = strMail & vbCrlf & "Phone: " & Request("Phone") strMail = strMail & vbCrlf & "Fax: " & Request("Fax") strMail = strMail & vbCrlf & "How dis you heard of PCCG: " & Request("HearFrom") strMail = strMail & vbCrlf & "Number of Modalities: " & vbCrlf strMail = strMail & "MRI: " & Request("ModMRI") & ", CT: " & Request("ModCT") & ", PET: " & Request("ModPET") strMail = strMail & ", US: " & Request("ModUS") & ", NM: " & Request("ModNM") & ", CR: " & Request("ModCR") & ", Others: " & Request("ModOthers") strMail = strMail & vbCrlf & vbCrlf & "Number of Annual Exams: " & vbCrlf strMail = strMail & "MRI: " & Request("AnnMRI") & ", CT: " & Request("AnnCT") & ", PET: " & Request("AnnPET") strMail = strMail & ", US: " & Request("AnnUS") & ", NM: " & Request("AnnNM") & ", CR: " & Request("AnnCR") & ", Others: " & Request("AnnOthers") strMail = strMail & vbCrlf & "Total Facility Annual Exams: " & Request("TotalAnnExams") strMail = strMail & vbCrlf & "PACS Desired Non-DICOM Modalities (Please list manufacturer & models): " & Request("PACSDesired") 'response.write(strMail) Dim objMail set objMail = Server.CreateObject("CDONTS.NewMail") objMail.To = "stephen@blueangelnet.com" objMail.From = Request("Email") objMail.Subject = "Request Products Information" objMail.Body = strMail objMail.send End If %> RIS Concept, Inc.
 
 
  REQUEST INFO
  <% if (Request("Submit") <> "") then response.write("We will response to your request soon!
Thank You!") response.write("














") else %>

Please tell us about how PCCG can best serve your needs.

Please fill out the form below.
(The more detailed the information the better we can help you).

Please send me : A Product Information Packet
Product Demo CD
     
Product Contact Methos : Email Phone
     
Product Interest (To select more than one Interest press the ctrl key while choosing)
Product Interest * :
Description of unique and / or specific requirements :
Planned PACS-RIS
purchase / implementation date		 : /
     
Facility / Professional Contact Information
First Name * :
Last Name * :
Email * :
Title/Position * :
    Others
Facility Description :
    Others
Company :
Address * :
City * :
State/Prov * :
Country * :
Zip/Postal Code * :
Phone * :
Fax :
How did you hear of PCCG?
:
     
Facility Modality Information (Please provide if appropriate)
  MRI CT PET US NM CR/RF Others  
# of Modalities  
# of Annual Exams
  
     
Total Facility Annual Exams
:
PACS Desired Non-DICOM Modalities (Please list manufacturer & models)
 :
     
   
     
<% end if %>