Your Name (*)
[text* your_name id:your_name]

Phone (*)
[tel* your_phone id:your_phone]

Email-Id (*)
[email* your_email_id id:your_email_id]

Requested date (*)
[date* req_date id:req_date]

Requested Time (*)
[select* req_time id:req_time “Select” “10 AM” “11 AM” “12 PM” “1 PM” “2 PM” “3 PM” “4 PM” “5 PM” “6 PM” “7 PM” ]

Type of Request
[select req_type id:req_type “Select” “First Visit” “Returning Patient”]

Appointment for
[select for_whom id:for_whom “Select” “Myself” “My Spouse” “My Childern” “My Family”]

[submit “Send”]

Appointment Request on [req_date]
[your-name] <[your_email_id]>
From: [your-name] <[your_email_id]>
Subject: Appointment Request on [req_date]

Name :[your_name]

Phone Number :[your_phone]

Email Id :[your_email_id]

Requested date :[req_date]

Requested Time :[req_time] :[ampm]

Type of Request :[req_type]

Appointment for :[for_whom]
test.bijimonap@gmail.com

[your-subject]
[your-name] <[your-email]>
Message Body:
[your-message]


This e-mail was sent from a contact form on divinespine (http://divinespine.ca)
[your-email]

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