www.dev2.delv-in.com - UnknownSec 403

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name : v_demo.php
 <div class='main_content_container'>


<h1>Request a Demo</h1>


<?php
	if ($_POST['submitBut'] == 'Submit'){

		$name = $_POST['name'];
		$practice = $_POST['practice'];
		$city = $_POST['city'];
		$position = $_POST['position'];
		$phone = $_POST['phone'];
		$email = $_POST['email'];
	
	} else {

		$name = '';
		$practice = '';
		$city = '';
		$position = '';
		$phone = '';
		$email = '';
	}


?>
    <div class='col-7'>
        <p>The best way to learn how DELVIN can make a difference in your practice is to take a personalized tour.</p>

        <p>We will show you how dental practices are benefiting from the knowledge and insight they are gaining from DELVIN. You'll get a first-hand look at DELVIN's user-friendly interface and see how you can start to gain valuable information about your practice within just a few weeks of adopting the program. A live demo usually takes between 30 and 60 minutes.</p>
    </div>
    <div class='col-4 request_form'>
        <div class='form_title'>Contact Me For A Demo</div>

        <form action='' method='post'>
        <div class='form_pair'><span>Name: </span><input type='text' name='name' value="<?php echo $name; ?>"></div>
        <div class='form_pair'><span>Practice: </span><input type='text' name='practice' value="<?php echo $practice; ?>"></div>
        <div class='form_pair'><span>City: </span><input type='text' name='city' value="<?php echo $city; ?>"></div>
        <div class='form_pair'><span>Position: </span><input type='text' name='position' value='<?php echo $position; ?>'></div>
        <div class='form_pair'><span>Phone: </span><input type='text' name='phone' value="<?php echo $phone; ?>"></div>
        <div class='form_pair'><span>Email: </span><input type='text' name='email' value="<?php echo $email; ?>"></div> 
        <div class='form_pair'><input type='submit' name='submitBut' value='Submit' class='submit_but' style='width:100%'></div>
    </form>
        
    </div>



</div> <!-- ends main_content_container -->
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