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Feedback forms to gather information

Here is an example of a feedback form from a medical site we designed. It is used to to gather information, generate prospects and make it easy for an interested visitor to request information on a topic that interests him or her.
When the sender submits it, a confirmation of what he has submitted is shown to him in the browser window, together with a link back to the page he was on. If he has not filled in some of the required fields (you select these) then an error message is shown to him.

(This form will not mail anything now, but you can still make selections and type in)

Get more information with this form:

Your details:

Name:

Email Address:

I would like more information on:

Resurfacing Knee Surgery
Resurfacing Hip Surgery.
Arthroscopy
Articular Cartilage Repair
Cruciate Ligament Reconstruction
Arthritis
Knee Replacement.
Hip Replacement
Sports injury
Exercise and Arthritis
Drugs and Arthritis

Would you like information on a subject not mentioned? Tell us here:


Do you want one of the staff to contact you?

Press and your request will be processed or to start again.
We aim to respond within 24 hours.

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