<% mode = request("mode") if mode="" then mode="form" if mode="process" then sql = "insert into tbltestimony (" & _ "fldinitials, fldcity, fldstate, flddatereceived, fldreversaldate, fldpregnantdate, fldtestimonial, fldtubelength, fldligationtype, fldapproved, age" & _ ") values (" & _ "'"&getum("fldinitials0")&"',"& _ "'"&getum("fldcity0")&"',"& _ "'"&getum("fldstate0")&"',"& _ "'"&getum("flddatereceived0")&"',"& _ "'"&getum("fldreversaldate0")&"',"& _ "'"&getum("fldpregnantdate0")&"',"& _ "'"&getum("fldtestimonial0")&"',"& _ "'"&getum("fldtubelength0")&"',"& _ "'"&getum("fldligationtype0")&"',"& _ "'no',"& _ "'"&getum("age0")&"'"& _ ")" dbexecute(sql) response.redirect request.servervariables("SCRIPT_NAME")&"?mode=success" end if if mode="success" then end if function getum(v) tmp = request(v) tmp = replace(tmp,"'","''") getum = tmp end function %> Tubal Reversal Testimonial by <%=v_fldinitials%> in <%=v_fldcity%>, <%=v_fldstate%>
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Tubal Ligation Reversal - Submit A Testimonial

<% if mode="form" then %>
Initials*
City*
State*
DateReceived Select  Clear
ReversalDate Select  Clear
PregnantDate Select  Clear
Testimonial*
TubeLength
LigationType
Age

');">    
<% end if %> <% if mode="success" then %>

Thank you for your submission! We will review it and post it shortly.

Go to Testimonials Page

<% end if %>



"Dr. Greene and the staff of the Lakeshore Surgical Center are simply wonderful."

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Gainesville, Georgia 30501

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Phone: 770-531-0012
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