<%@ LANGUAGE="VBScript" %> <% ' On Error Resume Next ' Classsic ASP pages created by Andre F Bruton ' E-mail: andre@bruton.co.za ' Date: 2008/01/19 pname = SQLEncode(Request("pname")) email = SQLEncode(Request("email")) intcode = SQLEncode(Request("intcode")) areacode = SQLEncode(Request("areacode")) phoneno = SQLEncode(Request("phoneno")) mobileintcode = SQLEncode(Request("mobileintcode")) mobile = SQLEncode(Request("mobile")) city = SQLEncode(Request("city")) states = SQLEncode(Request("states")) address = SQLEncode(Request("address")) comments = SQLEncode(Request("comments")) patientname = SQLEncode(Request("patientname")) patientemail = SQLEncode(Request("patientemail")) patientintcode = SQLEncode(Request("patientintcode")) patientareacode = SQLEncode(Request("patientareacode")) patientphone = SQLEncode(Request("patientphone")) patientmobileintcode = SQLEncode(Request("patientmobileintcode")) patientmobileno = SQLEncode(Request("patientmobileno")) patientcity = SQLEncode(Request("patientcity")) patientstate = SQLEncode(Request("patientstate")) patientaddress = SQLEncode(Request("patientaddress")) patientcomments = SQLEncode(Request("patientcomments")) cstatus = SQLEncode(Request("cstatus")) lookfor = SQLEncode(Request("lookfor")) recaptcha_challenge_field = Request("recaptcha_challenge_field") recaptcha_response_field = Request("recaptcha_response_field") recaptcha_private_key = "6LdTeLoSAAAAAC75m5T09Gjs9NIX-Naey4Al36My" recaptcha_public_key = "6LdTeLoSAAAAAOyq4XHU7Fx9ir_AGRUwHRFwdoow" browser = Request.ServerVariables("HTTP_USER_AGENT") ip = Request.ServerVariables("REMOTE_HOST") %> Medical Tourism India for Insurance Clients from Overseas Abroad
  India Hospital Tour by We Care India Medical tourism Company Surgery and Treatment in India by We Care India, Mumbai, Delhi, Chennai, Bangalore Surgery and Treatment in India at Low Cost JCI / ISO accredited hospital and experienced surgeon advantages
Medical tourism by We Care India for Low Cost Surgery and Treatment  at Hospitals in India your healthcare is now our concerns
Call: +91 9029304141 (10 am. To 8 pm. IST)
Post an EnquiryMedical Quote, Free No Obligation for Medical tourism Patients in India( Preferred )
(Only for international patients seeking treatment in India)
Only in India Hospital Tour
     
Refer A Patient
 

Refer A Patient

Bookmark and Share Go Back Print This Page Add to Favorites
|
Home > Refer A Patient

Refer A Patient


Are you a General Practitioner, a Doctor or are you involved in the healthcare service industry in your country? Do you want to refer a patient treatment or surgery to India

If Yes, Please fill the given form and send us immediately:


Your Details


    (*) Fields are mandatory

Your Name * :

 

Gender * :

  Male Female

Your E-Mail * :

 

Telephone * :

  Intl Code  

Area Code

Mobile * :

  Intl Code  

City * :

 

State * :

 

Country * :

 

Address * :

 

Your Message * :

 
     

Patients Details


    (*) Fields are mandatory

Patient Name * :

 

Gender:

  Male Female

Patient E-Mail:

 

Telephone :

  Intl Code  

Area Code

Mobile :

  Intl Code  

City:

 

State:

 

Country * :

 

Address:

 

Message * :

 

Clinical Status of the patient :

 

Treatment Looking for * :

 

Security Question * :

  <%=recaptcha_challenge_writer(recaptcha_public_key)%>
   
     
<% cTemp = recaptcha_confirm(recaptcha_private_key, recaptcha_challenge_field, recaptcha_response_field) If cTemp <> "" Then %>

An error occured with the recapture wording. Please try again. The error was Invalid Captcha Code


<% Else %> <% getemail=trim(Request.Form("email")) Dim iMsg Dim iConf Dim Flds Dim strHTML Dim strSmartHost dim email email=Request.Form("email") Const cdoSendUsingPort = 1 StrSmartHost = "mail.gmail.com" set iMsg = CreateObject("CDO.Message") set iConf = CreateObject("CDO.Configuration") dim strmess strmess="Query Form from India Hospital Tour
" strmess=strmess & "
Contact Message
" strmess=strmess & "
Details of "& Request.Form("pname") & " 
" strmess=strmess & "
Your Name :     "& Request.Form("pname") & "" strmess=strmess & "
Gender :     "& Request.Form("gender") & "" strmess=strmess & "
Email :     "& email strmess=strmess & "
Telephone Number :     "& Request.Form("intcode") & "" strmess=strmess & "   -   "& Request.Form("areacode") & "" strmess=strmess & "   -   "& Request.Form("phoneno") & "" strmess=strmess & "
Mobile Number :     "& Request.Form("mobileintcode") & "" strmess=strmess & "   -   "& Request.Form("mobile") & "" strmess=strmess & "
City :     "& Request.Form("city") & "" strmess=strmess & "
State :     "& Request.Form("states") & "" strmess=strmess & "
Country :     "& Request.Form("country") & "" strmess=strmess & "
Address :     "& Request.Form("address") & "" strmess=strmess & "
Your Message :     "& Request.Form("comments") & "

" strmess=strmess & "
"& Request.Form("patientname") & "  Details
" strmess=strmess & "
Name :     "& Request.Form("patientname") & "" strmess=strmess & "
Gender :     "& Request.Form("patientgender") & "" strmess=strmess & "
Email :     "& Request.Form("patientemail") & "" strmess=strmess & "
Telephone Number :     "& Request.Form("patientintcode") & "" strmess=strmess & "   -   "& Request.Form("patientareacode") & "" strmess=strmess & "   -   "& Request.Form("patientphone") & "" strmess=strmess & "
Mobile Number :     "& Request.Form("patientmobileintcode") & "" strmess=strmess & "   -   "& Request.Form("patientmobileno") & "" strmess=strmess & "
City :     "& Request.Form("patientcity") & "" strmess=strmess & "
State :     "& Request.Form("patientstate") & "" strmess=strmess & "
Country :     "& Request.Form("patientcountry") & "" strmess=strmess & "
Address :     "& Request.Form("patientaddress") & "" strmess=strmess & "
patient Message :     "& Request.Form("patientcomments") & "" strmess=strmess & "
Clinical Status of the patient :     "& Request.Form("cstatus") & "" strmess=strmess & "
Treatment Looking for :     "& Request.Form("lookfor") & "" Set Flds = iConf.Fields With Flds .Item("http://schemas.microsoft.com/cdo/configuration/sendusing") = cdoSendUsingPort .Item("http://schemas.microsoft.com/cdo/configuration/smtpserver") = strSmartHost .Item("http://schemas.microsoft.com/cdo/configuration/sendusername") = "info.wecareindia" .Item("http://schemas.microsoft.com/cdo/configuration/sendpassword") = "paperpaper" .Item("http://schemas.microsoft.com/cdo/configuration/smtpconnectiontimeout") = 10 .Item("http://schemas.microsoft.com/cdo/configuration/smtpserverport") = 26 .Item("http://schemas.microsoft.com/cdo/configuration/smtpauthenticate") = 1 .Item("http://schemas.microsoft.com/cdo/configuration/smtpserverpickupdirectory")="C:\Inetpub\mailroot\Pickup" .Update End With ' apply the settings to the message With iMsg Set .Configuration = iConf .To = "info.wecareindia@gmail.com" .BCC = "info.wecareindia@gmail.com" '.From = getemail .From = email '.From = "info.wecareindia@gmail.com" .Subject = "Query Form from India Hospital Tour" .HTMLBody = strmess .Send End With ' cleanup of variables Set iMsg = Nothing Set iConf = Nothing Set Flds = Nothing Response.Redirect("thanks.htm") %> <% End If %> <% ' The code below supplied by Mark Short ' returns string the can be written where you would like the reCAPTCHA challenged placed on your page function recaptcha_challenge_writer(publickey) recaptcha_challenge_writer = "" & _ "" & _ "" end function function recaptcha_confirm(privkey,rechallenge,reresponse) ' Test the captcha field Dim VarString VarString = _ "privatekey=" & privkey & _ "&remoteip=" & Request.ServerVariables("REMOTE_ADDR") & _ "&challenge=" & rechallenge & _ "&response=" & reresponse Dim objXmlHttp Set objXmlHttp = Server.CreateObject("Msxml2.ServerXMLHTTP") objXmlHttp.open "POST", "http://api-verify.recaptcha.net/verify", False objXmlHttp.setRequestHeader "Content-Type", "application/x-www-form-urlencoded" objXmlHttp.send VarString Dim ResponseString ResponseString = split(objXmlHttp.responseText, vblf) Set objXmlHttp = Nothing if ResponseString(0) = "true" then ' They answered correctly recaptcha_confirm = "" else ' They answered incorrectly recaptcha_confirm = ResponseString(1) end if end function %>
^ Back to Top

For more information, medical assessment and medical quote send your detailed medical history and medical reports
as email attachment to
Email : - info@wecareindia.com
Call: +91 9029304141 (10 am. To 8 pm. IST)
(Only for international patients seeking treatment in India)

 
Send Response
 

Gender : Age :




  

For a detailed evaluation send patientís medical reports / X rays / doctors notes to info@wecareindia.com
 
Patient Story

Patient Storys

Successful heart surgery at We Care India partner hospital allows Robert Clarke to live a normal life despite a rare genetic disorder We Care india helped Robert find best super specialised surgeon for his rare conditions.

Read    : Robert's Story
See All : Patient's Success Stories

Related Link

Group Websites


Find us on

 
Medical Tourism Search Information For Professionals Resources
Hospitals By :

 

 
 
Neurosurgery, Brain Surgery, Epilepsy Surgery, Brain Tumor Surgery in India

SSL Certificate
Neurosurgery, Heart surgery, Brain Surgery , Brain Tumor Surgery in India
   
 

Copyright © 2009 - 2010 We Care India. All Rights Reserved.
Home | About Us | Site Map | Get a Quote | Disclaimer | Advertise With Us | Contact Us

 

Health Insurance, Medical Insurance, India Hospital Tour Insurance Agency, Health Insurance Services India, Corporate Health Insurance, Easy Travel Insurance Policy, Individual Health Insurance Services, Indian Health Insurance, Stand-Alone Health Insurance, India Hospital Tour Health Insurance, Online Health Insurance, Insurance Mall, Star Health, Feature Life Insurance