"; } if(!empty($_POST['email'])){ $email = $_POST['email']; }else{ $errs .= "Your Email
"; } if(!empty($_POST['question'])){ $question = $_POST['question']; }else{ $errs .= "Your Email
"; } $title = $_POST['title']; $practice = $_POST['practice']; $address = $_POST['address']; $address2 = $_POST['address2']; $city = $_POST['city']; $state = $_POST['state']; $zipcode = $_POST['zipcode']; $country = $_POST['country']; $phone = $_POST['phone']; $ext = $_POST['ext']; $fax = $_POST['fax']; if(isset($_POST['hear'])){ $hear = $_POST['hear']; }else{ $hear = ''; } $refer = $_POST['refer']; $solic = $_POST['solic']; $other = $_POST['other']; $subscribe = $_POST['subscribe']; /*referrals*/ switch ($hear){ case 'Tradeshow': $ref = ''; break; case 'Referred by': $ref = $refer; break; case 'Solicited by': $ref = $solic; break; case 'Other': $ref = $other; break; default: break; } if(empty($errs)){//looks good $header = "Reply-To: info@cghealthcaresolutions.com\r\n"."From: CGHealthcare Contact Form\r\n"; $to .= ", info@cowangunteski.com"; $su = "CGHealthcare Contact Form"; $bo = "FULLNAME: $fullname\n TITLE: $title\n PRACTICE: $practice\n EMAIL: $email\n ADDRESS1: $address\n ADDRESS2: $address2\n CITY: $city\n STATE: $state\n ZIP CODE: $zipcode\n COUNTRY: $country\n PHONE: $phone\n EXT: $ext\n FAX: $fax\n HEARD FROM: $hear - $ref\n SUBSCRIBE: $subscribe; QUESTION: $question"; //send mail $sent = mail($to, $su, $bo, $header); if($sent){$successful = "Thank You for your inquiry.";} } } ?> CG Healthcare Solutions, LLC - Contact Us
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CG Healthcare Solutions, LLC

Toms River, New Jersey Office
40 Bey Lea Road
Suite A202
Toms River, NJ 08753
Phone: 732-818-0067
Fax: 732-818-0087

Tinton Falls, New Jersey Office
730 Hope Road
Tinton Falls, NJ 07724
Phone:  732-676-4100

Fax:  732-676-4101

Please use this form below to contact us for more information

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$errs

";} ?> $successful";}?>
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