<% pubkey = "6LcFxAYAAAAAAH4wssezakO-pzFwL3HqmKF9csLv" privkey = "6LcFxAYAAAAAAAw-QV8VilWeh_YV06alKNPDpdFz" ' 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 challenge = Request.Form("recaptcha_challenge_field") form_response = Request.Form("recaptcha_response_field") if Request.Form("submit") <> "" AND recaptcha_confirm(privkey,challenge,form_response) = "" then Set MyCDONTSMail = CreateObject("CDONTS.NewMail") MyCDONTSMail.From = "noreply@cyberren.com" MyCDONTSMail.To = "info@cyberren.com" MyCDONTSMail.Subject ="Information Request" MyBody = "Information Request" & vbCrLf MyBody = MyBody & "Demographics" & vbCrLf MyBody = MyBody & "Facility: " & request.Form("facility") & vbCrLf MyBody = MyBody & "Name: " & request.Form("name") & vbCrLf MyBody = MyBody & "Title: " & request.Form("title") & vbCrLf MyBody = MyBody & "Address: " & request.Form("address") & vbCrLf MyBody = MyBody & "City: " & request.Form("city") & vbCrLf MyBody = MyBody & "Province/state: " & request.Form("state") & vbCrLf MyBody = MyBody & "Country: " & request.Form("country") & vbCrLf MyBody = MyBody & "Zip/Postal Code: " & request.Form("zip") & vbCrLf MyBody = MyBody & "Telephone: " & request.Form("telephone") & vbCrLf MyBody = MyBody & "Fax: " & request.Form("fax") & vbCrLf MyBody = MyBody & "Email: " & request.Form("email") & vbCrLf MyBody = MyBody & "Please... " & request.Form("todo") & vbCrLf MyBody = MyBody & "We are... " & request.Form("weare") & vbCrLf MyBody = MyBody & "Hemo Patients: " & request.Form("hemo") & vbCrLf MyBody = MyBody & "PD Patients: " & request.Form("PD") & vbCrLf MyBody = MyBody & "Machine types: " & request.Form("machine") & vbCrLf MyBody = MyBody & "Other Machine Types: " & request.Form("other") & vbCrLf MyBody = MyBody & "Hospital Systems: " & request.Form("systems") & vbCrLf MyBody = MyBody & "Transplant Programme: " & request.Form("transplant") & vbCrLf MyBody = MyBody & vbCrLf MyBody = MyBody & vbCrLf MyBody = MyBody & "Key for ""We are...""" & vbCrLf MyBody = MyBody & "1 = Gathering Information" & vbCrLf MyBody = MyBody & "2 = Currently Evaluating Systems" & vbCrLf MyBody = MyBody & "3 = Looking to buy in 6 months" & vbCrLf MyBody = MyBody & "4 = Looking to buy in 12 months" & vbCrLf MyBody = MyBody & "" & vbCrLf MyCDONTSMail.Body = MyBody MyCDONTSMail.Send set MyCDONTSMail = nothing %>

Information Request Form


Thank-you

Your information has been sent and we will contact you as soon as possible.



Back to Home
<% else %>

Information Request Form

Your Demographics

You would like CML to ...      Call you      Send you information electronically

You are currently...   


Activities of your organization:

Hemodialysis: number of Hemo Patients
Peritoneal dialysis: number of PD Patients
Hemodialysis machine types
    Other:
Desired Links to Ancillary Systems
Transplant Program
Yes    No
Organization
Your Name
Your Title
Address
City
State/Province 
Country
Zip/Postal Code 
Telephone
Fax  
Email
<% if Request.Form("submit") <> "" AND recaptcha_confirm(privkey,challenge,form_response)<>"" then %>

To confirm data, please type the 2 words below in the red box.

<% end if Response.Write(recaptcha_challenge_writer(pubkey)) %>

or please call us @ 1.800.276.8128 for more information on the many features & benefits of cyberREN

<% end if %>
Contact   (C) Cybernius Medical 2017   Privacy Statement Legal Notice