$temp_profile->d_o_b = $fullDob; $temp_profile->driving_licence = mysql_real_escape_string($_REQUEST['driving_licence']); $temp_profile->user_address = mysql_real_escape_string($_REQUEST['user_address']); $temp_profile->user_state = mysql_real_escape_string($_REQUEST['user_state']); $temp_profile->user_city = mysql_real_escape_string($_REQUEST['user_city']); $temp_profile->zip_code = mysql_real_escape_string($_REQUEST['zip_code']); $temp_profile->doctor_name = mysql_real_escape_string($_REQUEST['doctor_name']); $temp_profile->client_email = mysql_real_escape_string($_REQUEST['client_email_address']); $case_type = "2"; $auto_insurance = ""; /*Convert to small letters*/ $username = strtolower(mysql_real_escape_string($_REQUEST['plantiff_name'])); $u_name1 = preg_replace('/\\s/', '', $username); $temp_profile->u_name = $u_name1; $ssn_no = ""; $var = $temp_profile->OldUser($case_type, $auto_insurance, $ssn_no); $emails = mysql_real_escape_string($_REQUEST['email_address']); $_SESSION['email'] = $emails; if ($var = 1) { echo "<div class='thank_message'>\n\t\t\t\t\tForm Submitted Sucessfully. You will redirected to next step shortly. Don't close the browser.</div>"; header("Refresh:2;url={$sitepath}/attorney/meshed-form/meshed-step-2.php/"); } else { echo "<div class='thank_message'>Email Sending Failed</div>"; } } ?> <div class="container client_application"> <h1>Mesh Registration Form</h1> <form name="registration" id="registration" method="post" action=""> <span class="error"></span> <div class="client_1">
$meshedform->office_no = mysql_real_escape_string($_REQUEST['office_no']); $meshedform->email_address = mysql_real_escape_string($_REQUEST['email_address']); $meshedform->d_o_b = mysql_real_escape_string($_REQUEST['d_o_b']); $meshedform->driving_licence = mysql_real_escape_string($_REQUEST['driving_licence']); $meshedform->user_address = mysql_real_escape_string($_REQUEST['user_address']); $meshedform->user_state = mysql_real_escape_string($_REQUEST['user_state']); $meshedform->user_city = mysql_real_escape_string($_REQUEST['user_city']); $meshedform->zip_code = mysql_real_escape_string($_REQUEST['zip_code']); $meshedform->doctor_name = mysql_real_escape_string($_REQUEST['doctor_name']); $case_type = "4"; $auto_insurance = " "; /*Convert to small letters*/ $username = strtolower(mysql_real_escape_string($_REQUEST['plantiff_name'])); $u_name1 = preg_replace('/\\s/', '', $username); $meshedform->u_name = $u_name1; $var = $meshedform->OldUser($case_type, $auto_insurance); echo $emails = mysql_real_escape_string($_REQUEST['email_address']); echo $_SESSION['email'] = $emails; if ($var = 1) { echo "<div id='e_message'>Your Login Information has been sent to your Email</div>"; header("Refresh:8;url={$sitepath}/attorney/meshed-form/meshed-step-2.php/"); } else { echo "<div id='e_message'>Email Sending Failed</div>"; } } require $get_footer; } else { header('Location:../../login.php'); } ?> <link rel="stylesheet" href="//code.jquery.com/ui/1.11.1/themes/smoothness/jquery-ui.css">