Please Fill out the Form Completely."; $subject = "REQUEST FOR APPOINTMENT"; $body = " Name: {$_POST['name']}\n Email: {$_POST['emailaddress']}\n Daytime Phone: {$_POST['dayphone']}\n Nighttime Phone: {$_POST['nightphone']}\n Appointment Preferences:\n {$_POST['preferences']}\n\n Connected from: \n" . gethostbyname($_SERVER['REMOTE_ADDR']) . "\n" . gethostbyaddr(gethostbyname($_SERVER['REMOTE_ADDR'])) . "\n"; mail("",$subject,$body,"From:"); mail("",$subject,$body,"From:"); mail("",$subject,$body,"From:"); mail("",$subject,$body,"From:"); unset($_POST); $issent = true; } } ?> Appointment Request Dr. James Schaller, MD
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Request an Appointment

James L. Schaller, M.D., M.A.R., P.C.

If you are a current patient and wish to set up an appointment please fill-in the form below and submit. If you wish to become a patient or receive a phone education consult regarding your medical care please call 239-263-0133 (USA)

Please provide three appointment options, Monday through Friday, 8:00 am to 4:30 pm.

Your request has been sent!

'); } else { echo('

Not sent: Please fill out the form completely and re-submit.

'); } } ?>

EMail Address

Daytime Phone Number

Nighttime Phone Number

Enter you preferred appointment dates/times

"); ?> In the box below, enter the numbers that appear, above, in red

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