<% ' 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 Session.LCID = 1033 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("docx-connect_ConnectionString") FP_DumpError strErrorUrl, "Cannot open database" fp_rs.Open "hosp_reg", 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(41) Dim arFormDBFields0(41) Dim arFormValues0(41) arFormFields0(0) = "comments1" arFormDBFields0(0) = "comments1" arFormValues0(0) = Request("comments1") arFormFields0(1) = "e_date_month" arFormDBFields0(1) = "e_date_month" arFormValues0(1) = Request("e_date_month") arFormFields0(2) = "hours_day" arFormDBFields0(2) = "hours_day" arFormValues0(2) = Request("hours_day") arFormFields0(3) = "s_date_yr" arFormDBFields0(3) = "s_date_yr" arFormValues0(3) = Request("s_date_yr") arFormFields0(4) = "doc_country" arFormDBFields0(4) = "doc_country" arFormValues0(4) = Request("doc_country") arFormFields0(5) = "wl_state" arFormDBFields0(5) = "wl_state" arFormValues0(5) = Request("wl_state") arFormFields0(6) = "post_code" arFormDBFields0(6) = "post_code" arFormValues0(6) = Request("post_code") arFormFields0(7) = "ww_sat" arFormDBFields0(7) = "ww_sat" arFormValues0(7) = Request("ww_sat") arFormFields0(8) = "ww_tue" arFormDBFields0(8) = "ww_tue" arFormValues0(8) = Request("ww_tue") arFormFields0(9) = "wl_address1" arFormDBFields0(9) = "wl_address1" arFormValues0(9) = Request("wl_address1") arFormFields0(10) = "ww_wed" arFormDBFields0(10) = "ww_wed" arFormValues0(10) = Request("ww_wed") arFormFields0(11) = "interp" arFormDBFields0(11) = "interp" arFormValues0(11) = Request("interp") arFormFields0(12) = "wl_address2" arFormDBFields0(12) = "wl_address2" arFormValues0(12) = Request("wl_address2") arFormFields0(13) = "Profession" arFormDBFields0(13) = "Profession" arFormValues0(13) = Request("Profession") arFormFields0(14) = "f_name" arFormDBFields0(14) = "f_name" arFormValues0(14) = Request("f_name") arFormFields0(15) = "Fax" arFormDBFields0(15) = "Fax" arFormValues0(15) = Request("Fax") arFormFields0(16) = "org_type" arFormDBFields0(16) = "org_type" arFormValues0(16) = Request("org_type") arFormFields0(17) = "Email" arFormDBFields0(17) = "Email" arFormValues0(17) = Request("Email") arFormFields0(18) = "City" arFormDBFields0(18) = "City" arFormValues0(18) = Request("City") arFormFields0(19) = "address1" arFormDBFields0(19) = "address1" arFormValues0(19) = Request("address1") arFormFields0(20) = "housing" arFormDBFields0(20) = "housing" arFormValues0(20) = Request("housing") arFormFields0(21) = "Specialty" arFormDBFields0(21) = "Specialty" arFormValues0(21) = Request("Specialty") arFormFields0(22) = "Phone" arFormDBFields0(22) = "Phone" arFormValues0(22) = Request("Phone") arFormFields0(23) = "address2" arFormDBFields0(23) = "address2" arFormValues0(23) = Request("address2") arFormFields0(24) = "org_name" arFormDBFields0(24) = "org_name" arFormValues0(24) = Request("org_name") arFormFields0(25) = "ww_sun" arFormDBFields0(25) = "ww_sun" arFormValues0(25) = Request("ww_sun") arFormFields0(26) = "ww_mon" arFormDBFields0(26) = "ww_mon" arFormValues0(26) = Request("ww_mon") arFormFields0(27) = "specilaty_other" arFormDBFields0(27) = "specilaty_other" arFormValues0(27) = Request("specilaty_other") arFormFields0(28) = "wl_city" arFormDBFields0(28) = "wl_city" arFormValues0(28) = Request("wl_city") arFormFields0(29) = "ww_fri" arFormDBFields0(29) = "ww_fri" arFormValues0(29) = Request("ww_fri") arFormFields0(30) = "e_date_day" arFormDBFields0(30) = "e_date_day" arFormValues0(30) = Request("e_date_day") arFormFields0(31) = "language" arFormDBFields0(31) = "language" arFormValues0(31) = Request("language") arFormFields0(32) = "food" arFormDBFields0(32) = "food" arFormValues0(32) = Request("food") arFormFields0(33) = "e_date_yr" arFormDBFields0(33) = "e_date_yr" arFormValues0(33) = Request("e_date_yr") arFormFields0(34) = "Website" arFormDBFields0(34) = "Website" arFormValues0(34) = Request("Website") arFormFields0(35) = "State" arFormDBFields0(35) = "State" arFormValues0(35) = Request("State") arFormFields0(36) = "ww_thu" arFormDBFields0(36) = "ww_thu" arFormValues0(36) = Request("ww_thu") arFormFields0(37) = "profession_number" arFormDBFields0(37) = "profession_number" arFormValues0(37) = Request("profession_number") arFormFields0(38) = "s_date_day" arFormDBFields0(38) = "s_date_day" arFormValues0(38) = Request("s_date_day") arFormFields0(39) = "s_date_month" arFormDBFields0(39) = "s_date_month" arFormValues0(39) = Request("s_date_month") arFormFields0(40) = "l_name" arFormDBFields0(40) = "l_name" arFormValues0(40) = Request("l_name") FP_SaveFormFields fp_rs, arFormFields0, arFormDBFields0 If Request.ServerVariables("HTTP_USER_AGENT") <> "" Then FP_SaveFieldToDB fp_rs, Request.ServerVariables("HTTP_USER_AGENT"), "Browser_type" End If If Request.ServerVariables("REMOTE_HOST") <> "" Then FP_SaveFieldToDB fp_rs, Request.ServerVariables("REMOTE_HOST"), "Remote_computer_name" 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:",_ "hosp_reg.asp",_ "Return to the form." End If End If Session.CodePage = Session("FP_OldCodePage") Session.LCID = Session("FP_OldLCID") %> Forms


Synonyms|Editors|Languages|Comments|Home|Sponsors|Health Information| Editor Updates

Hospital/Clinics Registration: Doctor and Health Personnel Request (help us to further develop this program, call 202 487 7662)

Contact First Name  Last Name

Organization Name

Address
Address2
City       State/Province     
Post Code   Country
Phone   Fax
Email  
Website (If applicable)   Type of Organization
   
Start Date End Date
   
Profession How many people with this profession
Specialty

  Other

Hold down CTRL key and click to select multiple options.
 

Work Location site if different than above

Address
Address2
City       State/Province     
What kind of Housing Can You Provide Food  
Language Required         Will you have interpreter available?   
General Comments
Work Week Number of hours /Day :                       

Mon        Tue        Wed      Thur      Fri            Sat     Sun                                                                                                                  

 Contact us by email