PHP Email Form Output (NEED PROGRAMMER)

Form needs to be sent with clean templated email output (using tables I presume). Needs to be good for printing. Form needs javascript alert boxes if required field is not entered upon clicking proceed button. Form will show progress meter at top.

Not sure if a database should/needs be used ... up to the programmer.


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CB = Checkbox
RB = Radio Button
IN = Input
TB = TextBox




--- New Page ---
Q: What services do you wish to complete? (Help Link)
CB: Will (Help Link)
CB: Living Will (Help Link)
CB: Health Care Surrogate (Help Link)
CB: Durable Power of Attorney (Help Link)

---(Will Alternative (if checked at begging)) ---

--- New Page ---
Q: Name:
IN: Name
Q: Address:
IN: Address IN: City IN: State IN: Zip
Q: Phone Number:
IN: Phone Number
Q: Fax:
IN: Fax
Q: Email:
IN: Email
Q: Are you of sound mind and able to physically sign your will?
RB: Yes
RB: No


--- New Page ---
Q: Names of children, if any. Include adopted children. Please indicate if any childern are deceased. (Help Link)
IN: Child 1
IN: Child 2
IN: Child 3
IN: Child 4
IN: Child 5

--- New Page ---
Q: Do any of your beneficiaries receive social security disability benefits? (Help Link)
TB: Beneficiaries and their Social Security benefits (please describe)
Q: Do you wish to make special bequests? (Help Link)
IN: Named beneficiary IN: Thing
IN: Named beneficiary IN: Thing
IN: Named beneficiary IN: Thing
IN: Named beneficiary IN: Thing
IN: Named beneficiary IN: Thing
Q: Do you wish to make any general bequests? (Help Link)
IN: Named beneficiary IN: Cash
IN: Named beneficiary IN: Cash
IN: Named beneficiary IN: Cash
IN: Named beneficiary IN: Cash
IN: Named beneficiary IN: Cash


--- New Page ---
Q: Which people or charities are to receive your residuary estate? (Help Link)
IN: Named beneficiary IN: Cash IN: Percentage
IN: Named beneficiary IN: Cash IN: Percentage
IN: Named beneficiary IN: Cash IN: Percentage
IN: Named beneficiary IN: Cash IN: Percentage
IN: Named beneficiary IN: Cash IN: Percentage
IN: Named beneficiary IN: Cash IN: Percentage
IN: Named beneficiary IN: Cash IN: Percentage
IN: Named beneficiary IN: Cash IN: Percentage
IN: Named beneficiary IN: Cash IN: Percentage
IN: Named beneficiary IN: Cash IN: Percentage
Q: Who is designated as your personal representative? (Help Link)
IN: Name IN: City IN: State IN: Phone
IN: Name IN: City IN: State IN: Phone
IN: Name IN: City IN: State IN: Phone


--- New Page ---
Q: Do you wish to have special burial instructions included in your will? (Help Link)
TB: Burial Instructions


--- New Page (Living Will Alternative (if checked at beginning)) ---

There is nothing in particular to ask here. I’ll probably just put a narrative about a living will (instead of a help link.) If they choose one at the beginning, we’ll just prepare it, but for the moment, there’s not really anything to ask the client.


--- New Page (Designation of a Health Care Surrogate Alternative (if checked at beginning)) --- (Help Link)
Q: Name:
IN: Name (Initial)
Q: Address:
IN: Address IN: City IN: Zip
Q: Phone Number:
IN: Phone

Q: Name:
IN: Name (Successor)
Q: Address:
IN: Address IN: City IN: Zip
Q: Phone Number:
IN: Phone

Q: Name:
IN: Name (Successor)
Q: Address:
IN: Address IN: City IN: Zip
Q: Phone Number:
IN: Phone


--- New Page (Durable Power of Attorney (if checked at beginning)) --- (Help Link)
Q: Name:
IN: Name (Initial)
Q: Address:
IN: Address IN: City IN: Zip
Q: Phone Number:
IN: Phone

Q: Name:
IN: Name (Successor)
Q: Address:
IN: Address IN: City IN: Zip
Q: Phone Number:
IN: Phone

Q: Name:
IN: Name (Successor)
Q: Address:
IN: Address IN: City IN: Zip
Q: Phone Number:
IN: Phone


--- New Page (Final Page)---
Q: Would you like to complete another will?
Yes: (if they choose yes, start form over again collecting new info)
RB: You
RB: Spouse (10% discount on checkout)
RB: Other

RB: No, I'd like to checkout


--- New Page ---
Form is submitted to email

PayPal button with total
2CheckOut button with total




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I am available IM if you would like to talk more live:
AIM: xxpbks31xx
YIM: rip_razor
MSN: rip_razor(at)hotmail.com




Thanks,
Kyle