<% ' 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 = "http://www.anasazimedical.com/submit_fail.htm" 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("Pre_Register_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(58) Dim arFormDBFields0(58) Dim arFormValues0(58) arFormFields0(0) = "Work_Phone_Area_Code" arFormDBFields0(0) = "Work_Phone_Area_Code" arFormValues0(0) = Request("Work_Phone_Area_Code") arFormFields0(1) = "Spouse_Work_Phone" arFormDBFields0(1) = "Spouse_Work_Phone" arFormValues0(1) = Request("Spouse_Work_Phone") arFormFields0(2) = "Emergency_Zip_Code" arFormDBFields0(2) = "Emergency_Zip_Code" arFormValues0(2) = Request("Emergency_Zip_Code") arFormFields0(3) = "Fathers_Street_Address_2" arFormDBFields0(3) = "Fathers_Street_Address_2" arFormValues0(3) = Request("Fathers_Street_Address_2") arFormFields0(4) = "ID_Certificate_Policy_Number" arFormDBFields0(4) = "ID_Certificate_Policy_Number" arFormValues0(4) = Request("ID_Certificate_Policy_Number") arFormFields0(5) = "First_Name" arFormDBFields0(5) = "First_Name" arFormValues0(5) = Request("First_Name") arFormFields0(6) = "Work_Phone" arFormDBFields0(6) = "Work_Phone" arFormValues0(6) = Request("Work_Phone") arFormFields0(7) = "Emergency_First_Name" arFormDBFields0(7) = "Emergency_First_Name" arFormValues0(7) = Request("Emergency_First_Name") arFormFields0(8) = "Emergency_Phone" arFormDBFields0(8) = "Emergency_Phone" arFormValues0(8) = Request("Emergency_Phone") arFormFields0(9) = "Mothers_First_Name" arFormDBFields0(9) = "Mothers_First_Name" arFormValues0(9) = Request("Mothers_First_Name") arFormFields0(10) = "Mothers_MI" arFormDBFields0(10) = "Mothers_MI" arFormValues0(10) = Request("Mothers_MI") arFormFields0(11) = "Secondary_Insurance_Company" arFormDBFields0(11) = "Secondary_Insurance_Company" arFormValues0(11) = Request("Secondary_Insurance_Company") arFormFields0(12) = "Zip_Code" arFormDBFields0(12) = "Zip_Code" arFormValues0(12) = Request("Zip_Code") arFormFields0(13) = "Email_Address" arFormDBFields0(13) = "Email_Address" arFormValues0(13) = Request("Email_Address") arFormFields0(14) = "Spouse_Name" arFormDBFields0(14) = "Spouse_Name" arFormValues0(14) = Request("Spouse_Name") arFormFields0(15) = "Emergency_MI" arFormDBFields0(15) = "Emergency_MI" arFormValues0(15) = Request("Emergency_MI") arFormFields0(16) = "Fathers_Zip_Code" arFormDBFields0(16) = "Fathers_Zip_Code" arFormValues0(16) = Request("Fathers_Zip_Code") arFormFields0(17) = "Secondary_ID_Certificate_Policy_Number" arFormDBFields0(17) = "Secondary_ID_Certificate_Policy_Number" arFormValues0(17) = Request("Secondary_ID_Certificate_Policy_Number") arFormFields0(18) = "Home_Phone_Area_Code" arFormDBFields0(18) = "Home_Phone_Area_Code" arFormValues0(18) = Request("Home_Phone_Area_Code") arFormFields0(19) = "Emergency_City" arFormDBFields0(19) = "Emergency_City" arFormValues0(19) = Request("Emergency_City") arFormFields0(20) = "Group_Number" arFormDBFields0(20) = "Group_Number" arFormValues0(20) = Request("Group_Number") arFormFields0(21) = "Additional_Information" arFormDBFields0(21) = "Additional_Information" arFormValues0(21) = Request("Additional_Information") arFormFields0(22) = "Emergency_Last_Name" arFormDBFields0(22) = "Emergency_Last_Name" arFormValues0(22) = Request("Emergency_Last_Name") arFormFields0(23) = "Fathers_Last_Name" arFormDBFields0(23) = "Fathers_Last_Name" arFormValues0(23) = Request("Fathers_Last_Name") arFormFields0(24) = "Mothers_Last_Name" arFormDBFields0(24) = "Mothers_Last_Name" arFormValues0(24) = Request("Mothers_Last_Name") arFormFields0(25) = "Mothers_State" arFormDBFields0(25) = "Mothers_State" arFormValues0(25) = Request("Mothers_State") arFormFields0(26) = "Fathers_City" arFormDBFields0(26) = "Fathers_City" arFormValues0(26) = Request("Fathers_City") arFormFields0(27) = "Last_Name" arFormDBFields0(27) = "Last_Name" arFormValues0(27) = Request("Last_Name") arFormFields0(28) = "Spouse_Work_Phone_Area_Code" arFormDBFields0(28) = "Spouse_Work_Phone_Area_Code" arFormValues0(28) = Request("Spouse_Work_Phone_Area_Code") arFormFields0(29) = "Emergency_State" arFormDBFields0(29) = "Emergency_State" arFormValues0(29) = Request("Emergency_State") arFormFields0(30) = "Mothers_Street_Address_1" arFormDBFields0(30) = "Mothers_Street_Address_1" arFormValues0(30) = Request("Mothers_Street_Address_1") arFormFields0(31) = "Day" arFormDBFields0(31) = "Day" arFormValues0(31) = Request("Day") arFormFields0(32) = "Fathers_First_Name" arFormDBFields0(32) = "Fathers_First_Name" arFormValues0(32) = Request("Fathers_First_Name") arFormFields0(33) = "Mothers_Street_Address_2" arFormDBFields0(33) = "Mothers_Street_Address_2" arFormValues0(33) = Request("Mothers_Street_Address_2") arFormFields0(34) = "Primary_Insurance_Company" arFormDBFields0(34) = "Primary_Insurance_Company" arFormValues0(34) = Request("Primary_Insurance_Company") arFormFields0(35) = "Emergency_Street_Address_1" arFormDBFields0(35) = "Emergency_Street_Address_1" arFormValues0(35) = Request("Emergency_Street_Address_1") arFormFields0(36) = "City" arFormDBFields0(36) = "City" arFormValues0(36) = Request("City") arFormFields0(37) = "Emergency_Street_Address_2" arFormDBFields0(37) = "Emergency_Street_Address_2" arFormValues0(37) = Request("Emergency_Street_Address_2") arFormFields0(38) = "Fathers_Phone_Area_Code" arFormDBFields0(38) = "Fathers_Phone_Area_Code" arFormValues0(38) = Request("Fathers_Phone_Area_Code") arFormFields0(39) = "Home_Phone" arFormDBFields0(39) = "Home_Phone" arFormValues0(39) = Request("Home_Phone") arFormFields0(40) = "Fathers_Phone" arFormDBFields0(40) = "Fathers_Phone" arFormValues0(40) = Request("Fathers_Phone") arFormFields0(41) = "Mothers_Phone_Area_Code" arFormDBFields0(41) = "Mothers_Phone_Area_Code" arFormValues0(41) = Request("Mothers_Phone_Area_Code") arFormFields0(42) = "Mothers_Zip_Code" arFormDBFields0(42) = "Mothers_Zip_Code" arFormValues0(42) = Request("Mothers_Zip_Code") arFormFields0(43) = "Year" arFormDBFields0(43) = "Year" arFormValues0(43) = Request("Year") arFormFields0(44) = "Mothers_City" arFormDBFields0(44) = "Mothers_City" arFormValues0(44) = Request("Mothers_City") arFormFields0(45) = "MI" arFormDBFields0(45) = "MI" arFormValues0(45) = Request("MI") arFormFields0(46) = "Street_Address1" arFormDBFields0(46) = "Street_Address1" arFormValues0(46) = Request("Street_Address1") arFormFields0(47) = "Month" arFormDBFields0(47) = "Month" arFormValues0(47) = Request("Month") arFormFields0(48) = "Secondary_Group_Number" arFormDBFields0(48) = "Secondary_Group_Number" arFormValues0(48) = Request("Secondary_Group_Number") arFormFields0(49) = "Street_Address2" arFormDBFields0(49) = "Street_Address2" arFormValues0(49) = Request("Street_Address2") arFormFields0(50) = "Marital_Status" arFormDBFields0(50) = "Marital_Status" arFormValues0(50) = Request("Marital_Status") arFormFields0(51) = "State" arFormDBFields0(51) = "State" arFormValues0(51) = Request("State") arFormFields0(52) = "Fathers_MI" arFormDBFields0(52) = "Fathers_MI" arFormValues0(52) = Request("Fathers_MI") arFormFields0(53) = "Gender" arFormDBFields0(53) = "Gender" arFormValues0(53) = Request("Gender") arFormFields0(54) = "Emergency_Phone_Area_Code" arFormDBFields0(54) = "Emergency_Phone_Area_Code" arFormValues0(54) = Request("Emergency_Phone_Area_Code") arFormFields0(55) = "Fathers_Street_Address_1" arFormDBFields0(55) = "Fathers_Street_Address_1" arFormValues0(55) = Request("Fathers_Street_Address_1") arFormFields0(56) = "Fathers_State" arFormDBFields0(56) = "Fathers_State" arFormValues0(56) = Request("Fathers_State") arFormFields0(57) = "Mothers_Phone" arFormDBFields0(57) = "Mothers_Phone" arFormValues0(57) = Request("Mothers_Phone") 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 Session("FP_SavedFields")=arFormFields0 Session("FP_SavedValues")=arFormValues0 Session.CodePage = Session("FP_OldCodePage") Session.LCID = Session("FP_OldLCID") Response.Redirect "http://www.anasazimedical.com/submit_success.htm" End If End If Session.CodePage = Session("FP_OldCodePage") Session.LCID = Session("FP_OldLCID") %> Anasazi Medical Associates - Pre-Register

Patient Information:

(* = Required Fields)

 

    *Last Name:     *First:   M.I.:    

         *Address:     *Home Phone:      -

           Address:       Work Phone:       -

                  *City:      *State:    *Zip: 

  *Date of Birth:           *Gender:        

                               Month       Day       Year

      Email Address:                   Marital Status:     

      Spouse Name:      Spouse Work Phone:    -     

In case of emergency (Nearest friend or relative not residing in the same household):

    Last Name:    First:   M.I.:    

         Address:       Phone:     -

         Address:   

                  City:                         State:       Zip:  

If patient is a minor (Please fill out information for one or both parents):

   

Father's Last Name:   First: M.I.:    

                     Address:   Phone:     -

                     Address:   

                              City:                    State:       Zip:  

 

Mother's Last Name: First: M.I.:    

                    Address:   Phone:     -

                    Address:   

                             City:                     State:       Zip:  

 

Insurance Information:

 

    Primary Insurance Company:       

    Group Number:    ID / Certificate / Policy Number:  

    Secondary Insurance Company: 

    Group Number:  ID / Certificate / Policy Number:  

 

Any additional comments or questions:

 

   

 

 

 
   
 
PRE-REGISTRATION
 		    
       

       
 
       
   

Anasazi Medical Associates

2055 S. Pacheco Street, Suite 600

Santa Fe, NM 87505

505-473-0390

© 2004, Anasazi Medical Associates, P.A., All Rights Reserved

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