Save and Restore Form Cookies example
Appointment Request

SAVE AND RESTORE FORM FIELD VALUES - This script will save all of your form fields in a cookie. It includes all text fields, radio button selections, checkbox values, etc. Then, when your visitor returns, all form fields are automatically repopulated with the same value that they entered on their last visit. By the way, this form also runs a validation script which requires all fields be entered.

First Name:
Middle Name:
Last Name:
Zip Code:
Phone Number:
Best Time To call:
Reason for Appointment:
Please select one of the following
New Patient:
Established patient,new problem:
Established patient, problem already under treatment:
Appointment Preferred on what Day of the Week?
Monday    Tuesday     Wednesday  Thursday     Friday   ANY 
Appointment Preferred on what Time of Day?
AM       PM
Request an Appointment
Click this button to send
your appointment request

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Copyright 2005, T. Davis Consulting, Inc.
Form Design by T. Davis Consulting Inc.