Please register and we will send you a username and password. <% If request("submit") <> "" THEN Set objEMail = Server.CreateObject("CDO.Message") Set objConfig = Server.CreateObject("CDO.Configuration") Set Confi = objConfig.Fields Confi("http://schemas.microsoft.com/cdo/configuration/sendusing") = 1 Confi("http://schemas.microsoft.com/cdo/configuration/smtpserverpickupdirectory") = "C:\inetpub\mailroot\pickup" Confi.Update Set objEMail.Configuration = objConfig objEMail.To = "mail@ambermedical.co.uk" objEMail.From = Request("Email Address") objEMail.Subject = "Healthcare Professional Login" objEMail.TextBody = Request("from") & vbCRLF & Request("Address Line 1") & vbCRLF & Request("Address Line 2") & vbCRLF & Request("Address Line 3") & vbCRLF & Request("town") & vbCRLF & Request("county") & vbCRLF & Request("Postcode") & vbCRLF & vbCRLF & "Phone: " & Request("Phone Number") & vbCRLF & "Fax: " & Request("Fax Number") objEMail.Send Set objEMail = Nothing Response.Write("Message Sent") Else %> <% End If %>

Name:
Address Line 1:
Address Line 2:
Address Line 3:
Town/City:
County:
Postcode:
Email Address:
Phone Number:
Fax Number: