<% Set Mailer = Server.CreateObject("SMTPsvg.Mailer") Mailer.FromName = "website" Mailer.FromAddress= "steinmail@vasweb.com" Mailer.RemoteHost = "mail.vasweb.com" Mailer.Username = "admin@vasweb.com" Mailer.Password = "7372569" Mailer.AddRecipient "Doug Stein", "steinmail@vasweb.com" Mailer.AddExtraHeader "X-MimeOLE:Produced vasweb.com" Mailer.Subject = "Website Information Request" strMsgHeader = "Form information follows" & vbCrLf for each qryItem in Request.Form strMsgInfo = strMsgInfo & qryItem & " - " & request.Form(qryItem) & vbCrLf next strMsgFooter = vbCrLf & "End of form information" Mailer.BodyText = strMsgHeader & strMsgInfo & strMsgFooter if Mailer.SendMail then Response.Write "Form information submitted..." else Response.Write "Mail send failure. Error was " & Mailer.Response end if set Mailer = Nothing %>

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What would you like to receive?   

 Vasectomy information that supplements what is in this website.

Vasectomy referrals list: A list of first names with phone numbers and/or e-mail addresses of men who have had vasectomies and who would be happy to share their experiences and answer any questions.

Reversal information that supplements what is in this website.

Reversal referrals list:  A list of first names and phone numbers of men who have had reversals and who would be happy to share their experiences and answer any questions.

Graphs of our office reversal results: sperm recovery and pregnancy vs. number of years since vasectomy (also in the reversal "Success Rates" page (link above), but even more up to date).
How would you like to receive this information? (Note: we will not receive your e-mail address when you submit this form if you do not provide it above.)

Please enter any specific vasectomy or reversal questions in the box below and Dr. Stein will respond promptly, usually within 24 hours.

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