If: (Action_Param: 'action', -Count) > 0; Email_Send: -Host='mail.pointinspace.com', -To='dr.z@dermatopathologyconsultations.com', -From='info@dermatopathologyconsultations.com', -Subject='Email Form - New Practice Registration' , -Body='The following form was submitted on your Web site:\r\r' + 'Name:\r' + (Action_Param: 'name') + '\r\r' + 'Email:\r' + (Action_Param: 'email') + '\r\r' + 'Telephone:\r' + (Action_Param: 'telephone') + '\r\r' + 'Organization:\r' + (Action_Param: 'organization') + '\r\r' + 'Role:\r' + (Action_Param: 'role') + '\r\r' + 'Topic:\r' + (Action_Param: 'topic') + '\r\r' + 'Physicians:\r' + (Action_Param: 'physicians') + '\r\r' + 'Staff:\r' + (Action_Param: 'staff') + '\r\r' + 'Date/Time:\r' + Date + '\r\r' + 'Client:\r' + Client_IP + ' ' + Client_Type + '\r\r'; /If; ?> DermatopathologyConsultations
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PRACTICE REGISTRATION FORM:

[If: (Action_Param: 'action', -Count) != '']

Thank you for registering your practice. You and the listed personel will be issued secure passwords to secure features of the website.

[Else]

Please fill out this simple form to register your practice.

Your Name:

Your Email Address:

Your Telephone Number:

Full Name and Address of Your Organization:

Please list full names and email addresses of the physicians and support staff (transcriptionists, slide room staff, etc) who should have permission to send materials and view the reports.

Physicians (Full Name, tittle, email address) :

Staff (Full Name and email address) :

[/If]

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