New Pilot Program Signup"; $html_content .= "

Organization: " . htmlspecialchars($organization) . "
Role: " . htmlspecialchars($role) . "
Contact Person: " . htmlspecialchars($contact_person) . "
Email: " . htmlspecialchars($email) . "
Phone: " . htmlspecialchars($phone) . "
Address / Region: " . htmlspecialchars($address) . "
Patients Served: " . htmlspecialchars($patients_served) . "
Main Challenges:
" . nl2br(htmlspecialchars($challenges)) . "

"; $text_content = "New Pilot Program Signup "; $text_content .= "Organization: " . $organization . " "; $text_content .= "Role: " . $role . " "; $text_content .= "Contact Person: " . $contact_person . " "; $text_content .= "Email: " . $email . " "; $text_content .= "Phone: " . $phone . " "; $text_content .= "Address / Region: " . $address . " "; $text_content .= "Patients Served: " . $patients_served . " "; $text_content .= "Main Challenges: " . $challenges . " "; // Use the generic sendMail function $result = MailService::sendMail($to, $subject, $html_content, $text_content, ['reply_to' => $email]); if (!empty($result['success'])) { header('Location: signup-thank-you.php'); exit; } else { // Log error, maybe set a generic error message for the user error_log('MailService Error: ' . ($result['error'] ?? 'Unknown error')); $errors['submit'] = 'Sorry, there was a problem sending your application. Please try again later.'; } } } // Include header include __DIR__ . '/index.php'; ?>

Join the Pilot Program

Become a part of the solution to medicine shortages. Fill out the form below to apply for the Kotkakey pilot program.

Organization / Pharmacy Name

Role

Contact Person

Phone

Address / Region

Number of Patients Served / Pharmacy Size

Main Shortage Challenges (Optional)

I agree to the processing of my data as described in the Privacy Policy and consent to be contacted about the pilot program.