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<?php
require_once "db.php";
$uid = mysqli_real_escape_string($conn, $_POST['uid']);
$imgname = mysqli_real_escape_string($conn, $_POST['imgname']);
$imgid = mysqli_real_escape_string($conn, $_POST['imgid']);
$sl_no = mysqli_real_escape_string($conn, $_POST['sl_no']);
$pa_fname = mysqli_real_escape_string($conn, $_POST['pa_fname']);
$pa_lname = mysqli_real_escape_string($conn, $_POST['pa_lname']);
$pa_address = mysqli_real_escape_string($conn, $_POST['pa_address']);
$pa_email = mysqli_real_escape_string($conn, $_POST['pa_email']);
$pa_contact = mysqli_real_escape_string($conn, $_POST['pa_contact']);
$pa_dob = mysqli_real_escape_string($conn, $_POST['pa_dob']);
$pa_city = mysqli_real_escape_string($conn, $_POST['pa_city']);
$pa_state = mysqli_real_escape_string($conn, $_POST['pa_state']);
$pa_zipcode = mysqli_real_escape_string($conn, $_POST['pa_zipcode']);
$pa_medical_claim_no = mysqli_real_escape_string($conn, $_POST['pa_medical_claim_no']);
$dr_fname = mysqli_real_escape_string($conn, $_POST['dr_fname']);
$dr_lname = mysqli_real_escape_string($conn, $_POST['dr_lname']);
$dr_physical_address = mysqli_real_escape_string($conn, $_POST['dr_physical_address']);
$dr_phone = mysqli_real_escape_string($conn, $_POST['dr_phone']);
$dr_city = mysqli_real_escape_string($conn, $_POST['dr_city']);
$dr_email = mysqli_real_escape_string($conn, $_POST['dr_email']);
$ag_fname = mysqli_real_escape_string($conn, $_POST['ag_fname']);
$ag_lname = mysqli_real_escape_string($conn, $_POST['ag_lname']);
$ag_physical_address = mysqli_real_escape_string($conn, $_POST['ag_physical_address']);
$ag_contact = mysqli_real_escape_string($conn, $_POST['ag_contact']);
$ag_state = mysqli_real_escape_string($conn, $_POST['ag_state']);
$ag_zip_code = mysqli_real_escape_string($conn, $_POST['ag_zip_code']);
$ag_dob = mysqli_real_escape_string($conn, $_POST['ag_dob']);
$ag_email = mysqli_real_escape_string($conn, $_POST['ag_email']);
if(mysqli_query($conn, "INSERT INTO form_data(user_id,img_name,img_id,sl_no,pa_fname, pa_lname,pa_address,pa_email,pa_contact,pa_dob,pa_city,pa_state,pa_zipcode,pa_medical_claim_no,dr_fname,dr_lname,dr_physical_address,dr_phone,dr_city,dr_email,ag_fname,ag_lname
,ag_physical_address,ag_contact,ag_state,ag_zip_code,ag_dob,ag_email)
VALUES('" . $uid . "','" . $imgname . "','" . $imgid . "','" . $sl_no . "','" . $pa_fname . "', '" . $pa_lname . "','" . $pa_address . "', '" . $pa_email . "','" . $pa_contact . "', '" . $pa_dob . "', '" . $pa_city . "', '" . $pa_state . "', '" . $pa_zipcode . "', '" . $pa_medical_claim_no . "', '" . $dr_fname . "', '" . $dr_lname . "', '" . $dr_physical_address. "', '" . $dr_phone. "', '" . $dr_city. "','" . $dr_email. "', '" . $ag_fname. "', '" . $ag_lname. "', '" . $ag_physical_address. "', '" . $ag_contact. "', '" . $ag_state. "', '" . $ag_zip_code. "', '" . $ag_dob. "', '" . $ag_email. "')")) {
echo '1';
} else {
echo "Error: " . $sql . "" . mysqli_error($conn);
}
mysqli_close($conn);
?>