[First Name:] Please Enter Your First Name"; } if(strlen($_POST['lastname']) < 2) { $err .= "
  • [Last Name:] Please Enter Your Last Name
  • "; } $_POST['emailadr'] = strtolower($_POST['emailadr']); if(!filter_var($_POST['emailadr'],FILTER_VALIDATE_EMAIL)) { $err .= "
  • [Email:] Enter a valid e-mail address.
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  • [Area Code/Phone Number:] Please Enter a complete phone number
  • "; } if(strlen($_POST['country']) < 2) { $err .= "
  • [Country:] Please Enter Your Location
  • "; } if(!isset($_POST['xrays'])) { $err .= "
  • [Digital Xrays:] Do you have digital xrays? Select Yes or No.
  • "; } if(!isset($err)) { $iphost = gethostbyaddr($_SERVER['REMOTE_ADDR']); $err = "
  • Your Info has been received. Thank You!
  • We will contact you to schedule after your payment has been received.
  • "; $body = "Consultation Request:\nName: {$_POST['firstname']} {$_POST['lastname']}\nEmail: {$_POST['emailadr']}\nPhone: {$_POST['preferredphone']}\nCountry: {$_POST['country']}\nIP: $iphost\nDigital Xrays: {$_POST['xrays']}\n"; mail("ronald@gombach.com","Consultation Request: ICNR",$body,"From: no-reply@icnr.com"); mail("rebecca@icnr.com","Consultation Request: Dental Whole Body Connection",$body,"From: no-reply@dentalwholebodyconnection.com"); // mail("ghsdoc@icnr.com","Consultation Request: Dental Whole Body Connection",$body,"From: no-reply@dentalwholebodyconnection.com"); $_SESSION['display_pay'] = true; } } } ?> Consultation Request Dental Whole Body Connection

    Consultations

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    "); } ?>

    Dr. Smith provides personal telephone consultations to patients and professionals on an international basis. His consultations are based on a comprehensive assessment of specific symptoms and concerns using the latest technologies from around the world and his own clinical research. If you would like to schedule a dental and/or nutritional telephone consultation please follow the instructions below. If you would like to schedule an in-person consultation, please contact us at 1-800-272-2323.

    How to schedule an Initial 1/2 Hour Telephone Consultation. (The cost is $350.00, pre-paid.)

    1. Complete the form below. A link to PayPal to make your payment will be provided after you submit your name, e-mail address and phone number for prepayment.
    2. Upon receipt of your payment, we will contact you by the email address you supplied asking you to provide the following information:
      • Where you live and the time zone (example: New York, USA EST)
      • The general days/hours that you can be available for your Initial Phone Consultation
      • Your phone number
      • If you have digital x-rays you can send them via e-mail as jpeg (jpg) images
      • We will then send you an email to schedule the date and time of your consultation. PLEASE NOTE: We have a strict 48 business hour cancellation policy. No refunds will be issued on cancellations or changes to your scheduled telephone consultation outside of the 48 hour window. Regular business hours are: Monday, Tuesday, and Thursday 9AM-5PM EST and Wednesday 9AM-1PM EST. In the event you need to re-schedule or cancel within the 48 hour window, please call 215-968-4781. We will not accept cancellations via email. Thank you.
    3. You will call Dr. Gerald Smith at your scheduled time to discuss your health related issues and get you started on your road to recovery. Please call: 215-968-4781.
    First Name:
    Last Name:
    Email Address:
    Area Code & Phone Number:
    IP:
    Country:
    Do you have
    digital x-rays
    available?
      /> Yes       /> No