?php require 'phpmailerautoload.php'; function ValidateEmail($email) { $pattern = '/^([0-9a-z]([-.\w]*[0-9a-z])*@(([0-9a-z])+([-\w]*[0-9a-z])*\.)+[a-z]{2,6})$/i'; return preg_match($pattern, $email); } function ReplaceVariables($code) { foreach ($_POST as $key => $value) { if (is_array($value)) { $value = implode(",", $value); } $name = "$" . $key; $code = str_replace($name, $value, $code); } $code = str_replace('$ipaddress', $_SERVER['REMOTE_ADDR'], $code); return $code; } if ($_SERVER['REQUEST_METHOD'] == 'POST' && isset($_POST['formid']) && $_POST['formid'] == 'complain_sectionform1') { $mailto = 'nmh2120@mareislander.com'; $mailfrom = isset($_POST['email']) ? $_POST['email'] : $mailto; $subject = 'Grievance form'; $message = 'Values submitted from web site form:'; $success_url = './error_page.php'; $error_url = './p_rights.html'; $csvFile = "./formdata.csv"; $error = ''; $autoresponder_from = ''; $autoresponder_subject = ''; $autoresponder_message = ''; $eol = "\n"; $mail = new PHPMailer(); $mail->IsSMTP(); $mail->Host = 'smtp.office365.com'; $mail->Port = 587; $mail->SMTPAuth = true; $mail->Username = 'schang@sjffcc.org'; $mail->Password = 'Haven6424'; $mail->SMTPSecure = 'tls'; $mail->Subject = stripslashes($subject); $mail->From = $mailfrom; $mail->FromName = $mailfrom; $mailto_array = explode(",", $mailto); for ($i = 0; $i < count($mailto_array); $i++) { if(trim($mailto_array[$i]) != "") { $mail->AddAddress($mailto_array[$i], ""); } } $mail->AddReplyTo($mailfrom); if (!ValidateEmail($mailfrom)) { $error .= "The specified email address is invalid!\n
"; } if (!empty($error)) { $errorcode = file_get_contents($error_url); $replace = "##error##"; $errorcode = str_replace($replace, $error, $errorcode); echo $errorcode; exit; } $internalfields = array ("submit", "reset", "send", "filesize", "formid", "captcha_code", "recaptcha_challenge_field", "recaptcha_response_field", "g-recaptcha-response"); $message .= $eol; $message .= "IP Address : "; $message .= $_SERVER['REMOTE_ADDR']; $message .= $eol; $message .= "Referer : "; $message .= $_SERVER['SERVER_NAME']; $message .= $_SERVER['PHP_SELF']; $message .= $eol; $logdata = ''; foreach ($_POST as $key => $value) { if (!in_array(strtolower($key), $internalfields)) { $logdata .= ','; if (!is_array($value)) { $message .= ucwords(str_replace("_", " ", $key)) . " : " . $value . $eol; $value = str_replace(",", " ", $value); $logdata .= $value; } else { $message .= ucwords(str_replace("_", " ", $key)) . " : " . implode(",", $value) . $eol; $logdata .= implode("|", $value); } } } $logdata = str_replace("\r", "", $logdata); $logdata = str_replace("\n", " ", $logdata); $logdata .= "\r\n"; $handle = fopen($csvFile, 'a') or die("can't open file"); $logtime = date("Y-m-d H:i:s,"); fwrite($handle, $logtime); fwrite($handle, $_SERVER['REMOTE_ADDR']); fwrite($handle, $logdata); fclose($handle); $mail->CharSet = 'ISO-8859-1'; if (!empty($_FILES)) { foreach ($_FILES as $key => $value) { if ($_FILES[$key]['error'] == 0) { $mail->AddAttachment($_FILES[$key]['tmp_name'], $_FILES[$key]['name']); } } } $mail->WordWrap = 80; $mail->Body = $message; if (!$mail->Send()) { die('PHPMailer error: ' . $mail->ErrorInfo); } $mail->ClearAddresses(); $mail->ClearAttachments(); $mail->Subject = stripslashes($autoresponder_subject); $mail->From = $autoresponder_from; $mail->FromName = $autoresponder_from; $mail->AddAddress($mailfrom, ""); $mail->AddReplyTo($autoresponder_from); $mail->IsHTML(false); $mail->WordWrap = 80; $mail->Body = $autoresponder_message; if (!$mail->Send()) { die('PHPMailer error: ' . $mail->ErrorInfo); } $successcode = file_get_contents($success_url); $successcode = ReplaceVariables($successcode); echo $successcode; exit; } ?> Patient Complaint
Patient Complaint  Form
Circle Your Clinic/Circule su Clinica:
For Quality Assurance Use Only
Patient Account Number:
Notes:
Initials: QA Employee
Date of Resolution:
Department/Departmento:
Name of Patient/Visitor/Nombre del Paciente/Visitante:
Date of Appointment/Fecha (mmddyyyy)
Time/Hora:
Address/Domicilio:
Telephone Number/Numero de telefono:
DOB/Fecha de Nacimiento(mmddyyyy):
Please describe the complaint and include any pertinent information(names and titles, etc.):
Por Favor de dar detalles de su queja. Incluya informacion como nombres, titulos, etc.:
Best time to call/Mejor hora para llamar:  Mon-Fri/Lunes-Viernes:
Patient's Signature/Firma del paciente:
Date:
Staff's Signature & Title:
DOB/Fecha de Nacimiento(mmddyyyy):
Quick Links
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O
O
O
O
O
O
O
O
QA Director:
Time/Hora:
Patient Complaint
Patient Complaint  Form
Circle Your Clinic/Circule su Clinica:
For Quality Assurance Use Only
Patient Account Number:
Notes:
Initials: QA Employee
Date of Resolution:
Department/Departmento:
Name of Patient/Visitor/Nombre del Paciente/Visitante:
Date of Appointment/Fecha (mmddyyyy)
Time/Hora:
Address/Domicilio:
Telephone Number/Numero de telefono:
DOB/Fecha de Nacimiento(mmddyyyy):
Please describe the complaint and include any pertinent information(names and titles, etc.):
Por Favor de dar detalles de su queja. Incluya informacion como nombres, titulos, etc.:
Best time to call/Mejor hora para llamar:  Mon-Fri/Lunes-Viernes:
Patient's Signature/Firma del paciente:
Date:
Staff's Signature & Title:
DOB/Fecha de Nacimiento(mmddyyyy):
QA Director:
Time/Hora:
Quick Links
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Suite 200
San Jose, CA 95148
P: (408)729-9700
F: (866) 931-7822
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