Insurance Form

<% ' FP_ASP ASP Automatically generated by a Frontpage Component. Do not Edit. On Error Resume Next Session("FP_OldCodePage") = Session.CodePage Session("FP_OldLCID") = Session.LCID Session.CodePage = 1252 Err.Clear strErrorUrl = "" If Request.ServerVariables("REQUEST_METHOD") = "POST" Then If Request.Form("VTI-GROUP") = "0" Then Err.Clear Set fp_conn = Server.CreateObject("ADODB.Connection") FP_DumpError strErrorUrl, "Cannot create connection" Set fp_rs = Server.CreateObject("ADODB.Recordset") FP_DumpError strErrorUrl, "Cannot create record set" fp_conn.Open Application("insurance_form_ConnectionString") FP_DumpError strErrorUrl, "Cannot open database" fp_rs.Open "Results", fp_conn, 1, 3, 2 ' adOpenKeySet, adLockOptimistic, adCmdTable FP_DumpError strErrorUrl, "Cannot open record set" fp_rs.AddNew FP_DumpError strErrorUrl, "Cannot add new record set to the database" Dim arFormFields0(14) Dim arFormDBFields0(14) Dim arFormValues0(14) arFormFields0(0) = "Address1" arFormDBFields0(0) = "Address1" arFormValues0(0) = Request("Address1") arFormFields0(1) = "Address2" arFormDBFields0(1) = "Address2" arFormValues0(1) = Request("Address2") arFormFields0(2) = "Insurance_Co" arFormDBFields0(2) = "Insurance_Co" arFormValues0(2) = Request("Insurance_Co") arFormFields0(3) = "Group_Number" arFormDBFields0(3) = "Group_Number" arFormValues0(3) = Request("Group_Number") arFormFields0(4) = "Agreed" arFormDBFields0(4) = "Agreed" arFormValues0(4) = Request("Agreed") arFormFields0(5) = "City" arFormDBFields0(5) = "City" arFormValues0(5) = Request("City") arFormFields0(6) = "Phone" arFormDBFields0(6) = "Phone" arFormValues0(6) = Request("Phone") arFormFields0(7) = "Name" arFormDBFields0(7) = "Name" arFormValues0(7) = Request("Name") arFormFields0(8) = "History" arFormDBFields0(8) = "History" arFormValues0(8) = Request("History") arFormFields0(9) = "Allgergies" arFormDBFields0(9) = "Allgergies" arFormValues0(9) = Request("Allgergies") arFormFields0(10) = "Medications" arFormDBFields0(10) = "Medications" arFormValues0(10) = Request("Medications") arFormFields0(11) = "Zip" arFormDBFields0(11) = "Zip" arFormValues0(11) = Request("Zip") arFormFields0(12) = "ID_Number" arFormDBFields0(12) = "ID_Number" arFormValues0(12) = Request("ID_Number") arFormFields0(13) = "State" arFormDBFields0(13) = "State" arFormValues0(13) = Request("State") FP_SaveFormFields fp_rs, arFormFields0, arFormDBFields0 If Request.ServerVariables("REMOTE_HOST") <> "" Then FP_SaveFieldToDB fp_rs, Request.ServerVariables("REMOTE_HOST"), "Remote_computer_name" End If If Request.ServerVariables("HTTP_USER_AGENT") <> "" Then FP_SaveFieldToDB fp_rs, Request.ServerVariables("HTTP_USER_AGENT"), "Browser_type" End If FP_SaveFieldToDB fp_rs, Now, "Timestamp" If Request.ServerVariables("REMOTE_USER") <> "" Then FP_SaveFieldToDB fp_rs, Request.ServerVariables("REMOTE_USER"), "User_name" End If fp_rs.Update FP_DumpError strErrorUrl, "Cannot update the database" fp_rs.Close fp_conn.Close FP_FormConfirmation "text/html; charset=windows-1252",_ "Form Confirmation",_ "Thank you for submitting the following information:",_ "insurance_form.asp",_ "Return to the form." End If End If Session.CodePage = Session("FP_OldCodePage") Session.LCID = Session("FP_OldLCID") %> Insurance Form

"By Seas, By Lands"

Name:
Address:

City:
State:
Zip:
Phone #:
Medical Problems/History
Allergies:
Current Medications:
Insurance Company:
Group Number:
Id Number:
I hereby give my consent to the nearest hospital/medical facility, to administer necessary treatment in the event of an emergency at which time I cannot be reached or responding. I give my permission to transport by ambulance if the situation warrants it.	Agreed Disagreed