<?php
 
// Change these two variables to meet your needs.
 
$myemail = 'myemail@domain.com';
$subject = 'Contact form Subject';
 
$op = $_POST[op];
 
if($op == 'contact')
{
    $name = stripslashes($_POST[name]);
    $email = stripslashes($_POST[email]);
    $text = stripslashes($_POST[text]);
    $referer = $_POST[referer];
    $remote_host = $_SERVER[REMOTE_ADDR];
    $server = $_SERVER[SERVER_NAME];
    $browser = $_SERVER[HTTP_USER_AGENT];
 
    if(!eregi("^[_a-z0-9-]+(\.[_a-z0-9-]+)*@[a-z0-9-]+(\.[a-z0-9-]+)*(\.[a-z]{2,4})$",$email)) 
    { 
        $status = "We're sorry, but you've entered an incorrect email address.<br>";
    }
    if(!$name)
    {
        $status .= "Please enter your name.<br>";
    }
    if(!$text)
    {
        $status .= "Please enter a message.<br>";
    }
 
    if(!$status)
    {
        $header = "From: $email\r\nReply-To: $email\r\n";
 
        $message = "
            Name: $name
            Referer: $referer
            Site: $server
            Remote Host: $remote_host
            Remote Browser: $browser
 
            $text
        ";
 
        if(mail($myemail, $subject, $message, $header))
        {
            $status = "Thank you for your Feedback!!<br><br>";
        }
        else
        {
            $status = "There was a problem sending your feedback, please try again later.<br><br>";
        }
 
    }
    else
    {
        $status .= "<br>Please press <u>back</u> on your browser to resubmit.<br><br>";
    }
}    
 
// Now check the referer page and ensure it's a proper URL
 
$referer = $_SERVER[HTTP_REFERER];
 
if(!preg_match('#^http://[a-z0-9-]+.([a-z0-9-]+.)?[a-z]+#i', $referer))
{
    unset($referer);
}
 
?>
 
<?php print $status; ?>
 
<form method="post" action="<?php print $_SELF; ?>">
<input type="hidden" name="op" value="contact">
<input type="hidden" name="referer" value="<?php print $referer; ?>">
Name<br><input name="name" size="35" value=""><br>
E-mail address<br><input name="email" size="35" value=""><br>
<br>Message<br><textarea name="text" cols="50" rows="10"></textarea><br><br>
<input type="submit" value="Send message!">
</form>
 
 
 

Commenting Options