Referral

<% If Not Request.Form("email") = "" then email = Request.Form("email") pn = Request.Form("patname") rn = Request.Form("refname") Addr=Request.Form("add") city=Request.Form("city") st=Request.Form("st") zip=Request.Form("zip") ph=Request.Form("phone") fx=Request.Form("fax") patmd=Request.Form("patmd") comm=Request.Form("comments") Set objMessage = CreateObject("CDO.Message") objMessage.from = email objMessage.To = "baisden.marsha@mccg.org;hill.cindy@mccg.org;sandoval.cathy@mccg.org" 'objMessage.BCC = "acortez@mansellgroup.com" objMessage.Subject = "Hospice Referral" objMessage.htmlBody = "" objMessage.htmlBody = objMessage.htmlBody & "The following referral was sent from the Hospice web site" & "

" objMessage.htmlBody = objMessage.htmlBody & "Patient Name" & " " & pn & "
" objMessage.htmlBody = objMessage.htmlBody & "Person Making Referral:" & " " & rn & "
" objMessage.htmlBody = objMessage.htmlBody & "Address:" & " " & addr & " " objMessage.htmlBody = objMessage.htmlBody & city & ", " & st & " " & zip & "
" objMessage.htmlBody = objMessage.htmlBody & "Phone: " & " " & ph & "
" objMessage.htmlBody = objMessage.htmlBody & "Fax: " & " " & fx & "
" objMessage.htmlBody = objMessage.htmlBody & "Patient's Doctor: " & " " & patmd & "
" objMessage.htmlBody = objMessage.htmlBody & "Additional Comments: " & " " & comm & "

" objMessage.Configuration.Fields.Item _ ("http://schemas.microsoft.com/cdo/configuration/sendusing") = 2 'Name or IP of Remote SMTP Server objMessage.Configuration.Fields.Item _ ("http://schemas.microsoft.com/cdo/configuration/smtpserver") = "xx.xxx.xxx.xxx" 'Server port (typically 25) objMessage.Configuration.Fields.Item _ ("http://schemas.microsoft.com/cdo/configuration/smtpserverport") = 25 objMessage.Configuration.Fields.Update '==End remote SMTP server configuration section== objMessage.Send 'Display message Response.Write "

" Response.Write "Your request has been submitted.
Thank you.

" Else %>

Make a Referral

The emailed information you provide on this page may not be reviewed until the day after submission to Hospice of Central Georgia.

For faster service, contact us at 478-633-5660 or 1-800-211-1084 and ask for an admissions counselor or print this completed referral page and fax it to us at
478-781-3348.

" method="post" name="refer">

Patient Name:
Person Referring:
Address
City
State, Zip
Email
Phone
Fax
Patient's Physician
Comments/Questions

<% End if%>