Make an Appointment Patient Portal Make a Payment

Family Medicine & Diabetes Care

Healing humanity through science and compassion, one patient at a time.

test3216549877


// Shortcode function for the form
function simple_test_form() {
$output = '';

// Check if form is submitted
if ( isset($_POST['submit_test_form']) ) {
$name = sanitize_text_field($_POST['name']);
$dob = sanitize_text_field($_POST['dob']);

// Simple confirmation
$output .= ‘

Thank you, ‘ . esc_html($name) . ‘! Your DOB is ‘ . esc_html($dob) . ‘.

‘;
}

// The form HTML
$output .= ‘

‘;

return $output;
}

// Register the shortcode [simple_test_form]
add_shortcode(‘simple_test_form’, ‘simple_test_form’);
?>