contrib/forms/contacts/new.php

   1 <!-- Form generated from formsWiz -->
   2 <?php
   3 include_once("../../globals.php");
   4 include_once("$srcdir/api.inc");
   5 formHeader("Form: contacts");
   6 ?>
   7 <html><head>
   8 <?php html_header_show();?>
   9 <link rel=stylesheet href="<?php echo $css_header;?>" type="text/css">
  10 </head>
  11 <body <?php echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  12 <form method=post action="<?php echo $rootdir;?>/forms/contacts/save.php?mode=new" name="my_form">
  13 <span class="title">Contacts</span><br><br>
  14 <table>
  15 <tr>
  16 <td valign=top>
  17 <table>
  18 <tr><td><span class=text>OD Base Curve: </span></td><td><input size=4 type=entry name="od_base_curve" value="" ></td></tr>
  19 <tr><td><span class=text>OD Sphere: </span></td><td><input size=4 type=entry name="od_sphere" value="" ></td></tr>
  20 <tr><td><span class=text>OD Cylinder: </span></td><td><input size=4 type=entry name="od_cylinder" value="" ></td></tr>
  21 <tr><td><span class=text>OD Axis: </span></td><td><input size=4 type=entry name="od_axis" value="" ></td></tr>
  22 <tr><td><span class=text>OD Diameter: </span></td><td><input size=4 type=entry name="od_diameter" value="" ></td></tr>
  23 </table>
  24 </td>
  25 <td valign=top>
  26 <table>
  27 <tr><td><span class=text>OS Base Curve: </span></td><td><input size=4 type=entry name="os_base_curve" value="" ></td></tr>
  28 <tr><td><span class=text>OS Sphere: </span></td><td><input size=4 type=entry name="os_sphere" value="" ></td></tr>
  29 <tr><td><span class=text>OS Cylinder: </span></td><td><input size=4 type=entry name="os_cylinder" value="" ></td></tr>
  30 <tr><td><span class=text>OS Axis: </span></td><td><input size=4 type=entry name="os_axis" value="" ></td></tr>
  31 <tr><td><span class=text>OS Diameter: </span></td><td><input size=4 type=entry name="os_diameter" value="" ></td></tr>
  32 </table>
  33 </td>
  34 </tr>
  35 </table>
  36
  37 <table>
  38 <tr><td><span class=text>Material: </span></td><td><input size=4 type=entry name="material" value="" ></td>
  39 <td><span class=text>Color: </span></td><td><input size=4 type=entry name="color" value="" ></td>
  40 <td><span class=text>Bifocal Type: </span></td><td><input size=4 type=entry name="bifocal_type" value="" ></td>
  41 <td><span class=text>Add: </span></td><td><input size=4 type=entry name="add_value" value="" ></td>
  42 <td><span class=text>V/A Far: </span></td><td><input size=4 type=entry name="va_far" value="" ></td>
  43 <td><span class=text>V/A Near: </span></td><td><input size=4 type=entry name="va_near" value="" ></td>
  44 </tr>
  45 </table>
  46
  47 <table>
  48 <tr>
  49 <td valign=top>
  50 <span class=text>Additional Notes: </span><br><textarea cols=40 rows=8 wrap=virtual name="additional_notes" ></textarea><br>
  51 </td>
  52 </tr>
  53 </table>
  54 <br>
  55 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
  56 <br>
  57 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link"
  58  onclick="top.restoreSession()">[Don't Save]</a>
  59 </form>
  60 <?php
  61 formFooter();
  62 ?>