| Picture of Yourself Closeup: | view | ";
} else {
$error = "Sorry, there was an error uploading your file.";
}
} else {
$error = "Sorry, only JPG, JPEG, PNG, and GIF files are allowed.";
}
}
// Construct the email headers
$headers = "MIME-Version: 1.0\r\n";
$headers .= "Content-Type: text/html; charset=UTF-8\r\n";
$emailBody .= "| Client's First Name* | $name1 |
|---|
";
$emailBody .= "| Client's Last Name* | $name2 |
|---|
";
$emailBody .= "| Mother's Name (If A Minor) | $name3 |
|---|
";
$emailBody .= "| Age of Client* | $age |
|---|
";
$emailBody .= "| Email Address* | $email |
|---|
";
$emailBody .= "| Phone* | $phone |
|---|
";
$emailBody .= "| Street Address* | $saddress |
|---|
";
$emailBody .= "| Apartment, suite, etc | $appartment |
|---|
";
$emailBody .= "| City* | $city |
|---|
";
$emailBody .= "| State/Province* | $state |
|---|
";
$emailBody .= "| ZIP / Postal Code* | $zip |
|---|
";
$emailBody .= "| Do You Need Help With A Skincare Routine? * | $helpSkin |
|---|
";
$emailBody .= "| How Did You Hear About Me? * | $fbg
$google
$friends
$other |
|---|
";
$emailBody .= "| What Are Your Specific Concerns/Challenges With Your Skin? How Long Have You Been Struggling With These Concerns/Challenges? Be Specific On What You Hope To Achieve From Your Treatment Today* | $today |
|---|
";
$emailBody .= "| Do You Have Dental Implants, A Pacemaker Or Body Piercings? * | $dentalImplants |
|---|
";
$emailBody .= "| Do You Have Any Allergies, Including Foods, Skin Products Or Ingredients, Animals, Etc.? * | $allergies |
|---|
";
$emailBody .= "| List Any And All Prescription Meds, Oral And Topical That You Use Or Have Used In The Past Year (Trentinoin, Lipitor, Etc) * | $prescription |
|---|
";
$emailBody .= "| Have You Had Any Dermaplaning, Microneedling, Botox, Injectables, Dermal Fillers Or Any Other Advanced Facial Or Cosmetic Treatments Within The Last Month? * | $facial |
|---|
";
$emailBody .= "| Have You Ever/Are You Currently Using Accutane® (Acne Medication)? * | $acne |
|---|
";
$emailBody .= "| Have You Had Any Chemical Peels, Microdermabrasion Or Any Resurfacing Treatments Within The Last Month? * | $peels |
|---|
";
$emailBody .= "| Please Specify If Any Of The Following Apply To You: * | $pregnant
$tryingToPreg
$lactating
$menstruating
$premenstrual
$premenopase
$inmenopause
$na |
|---|
";
$emailBody .= "| Have You Been Waxed Or Shaved Your Face Within The Last 72 Hours? * | $waxed |
|---|
";
$emailBody .= "| What Do U LIKE In A Treatment? This Is Not To Say You Will Get It All, Depending On Time And Skin Condition. It's A Way For Me To Get To Know What You Like. | $dedwarmer
$donttalk
$talk
$steam
$nosteam
$minimalsqueezing
$musicnowords
$musicwithwords |
|---|
";
$emailBody .= "| I Give My Permission For Diana Aka Diana's Earth To Post Any Videos Or Photos Of Services Performed On Me And Any Information Regarding The Services That I Have Received To Its Social Media Sites Including Its Website, Instagram, YouTube, Facebook And Tik Tok. * | $postv |
|---|
";
$emailBody .= "| Type Your Name In Box And It Will Serve As A Legally Binding E-Signature | $nametype |
|---|
";
// Include other form fields here...
$emailBody .= "";
$emailBody .= "