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Updated generic Imaging Req - for New Westminster area HTML Only Ver 2

Update: Sorry, JohnR. After Dr. Boxer asked me to take another look at things, I found an incomplete task - MedRay update was not finished. This should be the "final" version. If others are trying this, please let me know if the PHN is not autopopulating. JohnY ---- This is for docs in the New West area - it is a backgroundless, "generic" imaging req with the quick-pick menu lifted from the hospital form. CML has bought up a bunch of existing clinics, and changed their scope of services somewhat. Some of the hours at Brooke have expanded, and others have contracted. Not able to find much on Brooke on the web, but fortunately, all the needed details available on (shhhhh…) Pathways. JohnY

HTML icon GenericImagingNewWest_NoBG-X-BoxesVer2.html — HTML, 47 kB (48347 bytes)

File contents

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			// shows the forms on development machine from notepad ++ - saves you from uploading to the server to input alignments
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<div id="page1" style="position:relative; left:0px; top:0px; width:850px;" class="pagebreak">

<span style="position:absolute; left:10px; top:5px; width:750px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:40px; text-align:center; background-color:transparent;">Outpatient Radiology</span>

<span style="position:absolute; left:10px; top:50px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; background-color:transparent;">Patient Information:</span>
<span style="position:absolute; left:10px; top:85px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; background-color:transparent;">Name: </span>
<input name="PatientName" id="PatientName" type="text" class="noborder" style="position:absolute; left:65px; top:85px; width:232px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:16px; text-align:left; background-color:transparent;" oscarDB=patient_name>

<span style="position:absolute; left:10px; top:120px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; background-color:transparent;">DOB: </span>
<input name="DOB" id="DOB" type="text" class="noborder" style="position:absolute; left:65px; top:120px; width:232px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:16px; text-align:left; background-color:transparent;" oscarDB=DOB>

<span style="position:absolute; left:10px; top:155px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; background-color:transparent;">Phone: </span>
<input name="PtPhone" id="PtPhone" type="text" class="noborder" style="position:absolute; left:65px; top:155px; width:232px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:16px; text-align:left; background-color:transparent;" oscarDB=phone>

<span style="position:absolute; left:10px; top:190px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; background-color:transparent;">PHN: </span>
<input name="PHN" id="PHN" type="text" class="noborder" style="position:absolute; left:65px; top:190px; width:232px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:16px; text-align:left; background-color:transparent;" oscarDB=HINc>

<span style="position:absolute; left:10px; top:225px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; background-color:transparent;">Appt: </span>
<input name="Appt" id="Appt" type="text" class="noborder" style="position:absolute; left:65px; top:225px; width:232px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:16px; text-align:left; background-color:transparent;" value="">

<span style="position:absolute; left:390px; top:50px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; background-color:transparent;">Referring Doctor: </span>
<span style="position:absolute; left:590px; top:50px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; background-color:transparent;">Date: </span>
<input name="TodaysDate" id="TodaysDate" type="text" style="position:absolute; left:630px; top:50px; width:140px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:16px; text-align:center; background-color:transparent;" oscarDB=today>
<input name="CurrentUser" id="CurrentUser" type="text" style="position:absolute; left:390px; top:70px; width:380px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:16px; text-align:left; background-color:transparent;" oscarDB=current_user>
<textarea name="ClinicLabel" id="ClinicLabel" type="text" style="position:absolute; left:390px; top:92px; width:380px; height:101px; font-family:Arial; font-size:16px; text-align:left; font-weight:bold;" oscarDB=clinic_label></textarea>

<span style="position:absolute; left:390px; top:198px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; background-color:transparent;">Copy To: </span>
<input name="Copies" type="text" class="noborder" style="position:absolute; left:460px; top:197px; width:310px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:16px; text-align:left; background-color:transparent;" value="">

<span style="position:absolute; left:390px; top:225px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; background-color:transparent;">Billable To: </span>
<span style="position:absolute; left:507px; top:225px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; background-color:transparent;">MSP</span>
<input name="MSP" id="MSP" type="text" style="position:absolute; left:482px; top:225px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">

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<span style="position:absolute; left:10px; top:275px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; background-color:transparent;">Exam:</span>
<textarea name="ExamRequestedText" id="ExamRequestedText" type="text" style="position:absolute; left:65px; top:275px; width:705px; height:20px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:16px; text-align:left;" value=""></textarea>

<span style="position:absolute; left:10px; top:305px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; background-color:transparent;">Clinical Information:</span>
<textarea name="RelevantHistoryText" id="RelevantHistoryText" style="position:absolute; left:165px; top:305px; width:605px; height:55px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:16px; text-align:left;"></textarea>

<span style="position:absolute; left:10px; top:365px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; background-color:transparent;">Patient Instructions:</span>
<textarea name="PtInstructions" id="PtInstructions" style="position:absolute; left:165px; top:365px; width:605px; height:125px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:16px; text-align:left;"></textarea>

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<span style="position:absolute; left:30px; top:970px; width:740px; border:1px solid #808080;"></span>

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<span name="Site1name" class="noborder" style="position:absolute; left:65px; top:510px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:left; background-color:transparent;">CML HealthCare</span>
<span name="Site1address" class="noborder" style="position:absolute; left:65px; top:525px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">#B1 - 625-5th Ave.</span>
<span name="Site1City"  class="noborder" style="position:absolute; left:65px; top:540px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">New Westminster</span>
<span name="Site1Phone"  class="noborder" style="position:absolute; left:65px; top:555px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Phone 604-522-6818</span>
<span name="Site1Fax"  class="noborder" style="position:absolute; left:65px; top:570px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Fax 604-522-6810</span>
<span name="Site1Services" class="noborder" style="position:absolute; left:65px; top:585px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">UXF M-F 8:30-5:30 Sa 8:30-4:00</span>

<input name="Field2" id="Field2" type="text" style="position:absolute; left:260px; top:510px; width:16px; height:16px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<span name="Site2name" class="noborder" style="position:absolute; left:285px; top:510px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:left; background-color:transparent;">CML HealthCare</span>
<span name="Site2address" class="noborder" style="position:absolute; left:285px; top:525px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">#401 - 233 Nelson's Crescent</span>
<span name="Site2City" class="noborder" style="position:absolute; left:285px; top:540px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">New Westminster</span>
<span name="Site2Phone" class="noborder" style="position:absolute; left:285px; top:555px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Phone 604-526-2466</span>
<span name="Site2Fax" class="noborder" style="position:absolute; left:285px; top:570px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Fax 604-521-5904</span>
<span name="Site2Services" class="noborder" style="position:absolute; left:285px; top:585px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">X M-F 8:00-5:00</span>

<input name="Field3" id="Field3" type="text" style="position:absolute; left:480px; top:510px; width:16px; height:16px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<span name="Site3name" class="noborder" style="position:absolute; left:505px; top:510px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:left; background-color:transparent;">CML HealthCare</span>
<span name="Site3address" class="noborder" style="position:absolute; left:505px; top:525px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">#101 - 1015 Austin Ave.</span>
<span name="Site3City" class="noborder" style="position:absolute; left:505px; top:540px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Coquitlam</span>
<span name="Site3Phone" class="noborder" style="position:absolute; left:505px; top:555px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Phone 604-937-5588</span>
<span name="Site3Fax" class="noborder" style="position:absolute; left:505px; top:570px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Fax 604-936-8800</span>
<span name="Site3Services" class="noborder" style="position:absolute; left:505px; top:585px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">UXF M-F 8:30-5:30 Sa 8:30-3:00</span>

<input name="Field4" id="Field4" type="text" style="position:absolute; left:40px; top:630px; width:16px; height:16px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<span name="Site4name" class="noborder" style="position:absolute; left:65px; top:630px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:left; background-color:transparent;">North Surrey Medical Building</span>
<span name="Site4address" class="noborder" style="position:absolute; left:65px; top:645px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">#102 - 9656 King George Blvd</span>
<span name="Site4City" class="noborder" style="position:absolute; left:65px; top:660px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Surrey</span>
<span name="Site4Phone" class="noborder" style="position:absolute; left:65px; top:675px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Phone 604-581-4616</span>
<span name="Site4Fax" class="noborder" style="position:absolute; left:65px; top:690px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Fax 604-582-9022</span>
<span name="Site4Services" class="noborder" style="position:absolute; left:65px; top:705px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">XF M-F 8:30-5:00 Sa 8:30-12:30</span>

<input name="Field5" id="Field5" type="text" style="position:absolute; left:260px; top:630px; width:16px; height:16px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<span name="Site5name" class="noborder" style="position:absolute; left:285px; top:630px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:left; background-color:transparent;">Guildford Health Centre</span>
<span name="Site5address" class="noborder" style="position:absolute; left:285px; top:645px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">#3 - 15300 - 105th Ave.</span>
<span name="Site5City" class="noborder" style="position:absolute; left:285px; top:660px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Surrey</span>
<span name="Site5Phone" class="noborder" style="position:absolute; left:285px; top:675px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Phone 604-581-1101</span>
<span name="Site5Fax" class="noborder" style="position:absolute; left:285px; top:690px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Fax 604-582-8520</span>
<span name="Site5Services" class="noborder" style="position:absolute; left:285px; top:705px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">UXF M-F 8:30-5:30 Sa 8:30-12:30</span>

<input name="Field6" id="Field6" type="text" style="position:absolute; left:480px; top:630px; width:16px; height:16px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<span name="Site6name" class="noborder" style="position:absolute; left:505px; top:630px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:left; background-color:transparent;">Scott Road X-Ray Centre</span>
<span name="Site6address" class="noborder" style="position:absolute; left:505px; top:645px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">#104 - 8425 - 120th St.</span>
<span name="Site6City" class="noborder" style="position:absolute; left:505px; top:660px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Delta</span>
<span name="Site6Phone" class="noborder" style="position:absolute; left:505px; top:675px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Phone 604-590-2211</span>
<span name="Site6Fax" class="noborder" style="position:absolute; left:505px; top:690px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Fax 604-581-0405</span>
<span name="Site6Services" class="noborder" style="position:absolute; left:505px; top:705px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">UXMF M-F 8:30-6:00 Sa 8:30-4:30</span>

<input name="Field7" id="Field7" type="text" style="position:absolute; left:40px; top:750px; width:16px; height:16px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<span name="Site7name" class="noborder" style="position:absolute; left:65px; top:750px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:left; background-color:transparent;">Brooke Radiology Associates</span>
<span name="Site7address" class="noborder" style="position:absolute; left:65px; top:765px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">#100 - 4980 Kingsway</span>
<span name="Site7City" class="noborder" style="position:absolute; left:65px; top:780px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Burnaby</span>
<span name="Site7Phone" class="noborder" style="position:absolute; left:65px; top:795px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Phone 604-434-1345</span>
<span name="Site7Fax" class="noborder" style="position:absolute; left:65px; top:810px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Fax 604-435-1309</span>
<span name="Site7Services" class="noborder" style="position:absolute; left:65px; top:825px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">UXMB M-F 7:30-5:00</span>

<input name="Field8" id="Field8" type="text" style="position:absolute; left:260px; top:750px; width:16px; height:16px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<span name="Site8name" class="noborder" style="position:absolute; left:285px; top:750px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:left; background-color:transparent;">Brooke Radiology Associates</span>
<span name="Site8address" class="noborder" style="position:absolute; left:285px; top:765px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">#20 - 4218 East Hastings St.</span>
<span name="Site8City" class="noborder" style="position:absolute; left:285px; top:780px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Burnaby</span>
<span name="Site8Phone" class="noborder" style="position:absolute; left:285px; top:795px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Phone 604-299-2666</span>
<span name="Site8Fax" class="noborder" style="position:absolute; left:285px; top:810px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Fax 604-299-5773</span>
<span name="Site8Services" class="noborder" style="position:absolute; left:285px; top:825px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">UXM M-F 8:30-5:00</span>

<input name="Field9" id="Field9" type="text" style="position:absolute; left:480px; top:750px; width:16px; height:16px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<span name="Site9name" class="noborder" style="position:absolute; left:505px; top:750px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:left; background-color:transparent;">MedRay Imaging</span>
<span name="Site9address" class="noborder" style="position:absolute; left:505px; top:765px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">#100 - 3001 Gordon Ave.</span>
<span name="Site9City" class="noborder" style="position:absolute; left:505px; top:780px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Coquitlam</span>
<span name="Site9Phone" class="noborder" style="position:absolute; left:505px; top:795px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Phone 604-941-7611</span>
<span name="Site9Fax" class="noborder" style="position:absolute; left:505px; top:810px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Fax 604-942-4612</span>
<span name="Site9Services" class="noborder" style="position:absolute; left:505px; top:825px; width:260px; height:16px; font-family:sans-serif; font-style:normal; font-size:11px; text-align:left; background-color:transparent;">UXBM-MRI M-F 8:00-5:30 (Th 8:30 pm)</span>
<span name="Site9Servicesb" class="noborder" style="position:absolute; left:505px; top:840px; width:260px; height:16px; font-family:sans-serif; font-style:normal; font-size:11px; text-align:left; background-color:transparent;"> Sa 8:30-1:00</span>

<input name="Field10" id="Field10" type="text" style="position:absolute; left:40px; top:870px; width:16px; height:16px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<span name="Site10name" class="noborder" style="position:absolute; left:65px; top:870px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:left; background-color:transparent;">Valley Medical Imaging</span>
<span name="Site10address" class="noborder" style="position:absolute; left:65px; top:885px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">#200 - 5503 - 206th St.</span>
<span name="Site10City" class="noborder" style="position:absolute; left:65px; top:900px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Langley</span>
<span name="Site10Phone" class="noborder" style="position:absolute; left:65px; top:915px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Phone 604-534-4114</span>
<span name="Site10Fax" class="noborder" style="position:absolute; left:65px; top:930px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Fax 604-534-7877</span>
<span name="Site10Services" class="noborder" style="position:absolute; left:65px; top:945px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">UXMF M-F 8:00-5:00</span>

<input name="Field11" id="Field11" type="text" style="position:absolute; left:260px; top:870px; width:16px; height:16px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<span name="Site11name" class="noborder" style="position:absolute; left:285px; top:870px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:left; background-color:transparent;">Valley Medical Imaging</span>
<span name="Site11address" class="noborder" style="position:absolute; left:285px; top:885px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">45731 Patten Ave.</span>
<span name="Site11City" class="noborder" style="position:absolute; left:285px; top:900px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Chilliwack</span>
<span name="Site11Phone" class="noborder" style="position:absolute; left:285px; top:915px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Phone 604-795-7205</span>
<span name="Site11Fax" class="noborder" style="position:absolute; left:285px; top:930px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Fax 604-795-3543</span>
<span name="Site11Services" class="noborder" style="position:absolute; left:285px; top:945px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">X M-F 8:30-5:00</span>

<input name="Field12" id="Field12" type="text" style="position:absolute; left:480px; top:870px; width:16px; height:16px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<span name="Site12name" class="noborder" style="position:absolute; left:505px; top:870px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:left; background-color:transparent;">Valley Medical Imaging</span>
<span name="Site12address" class="noborder" style="position:absolute; left:505px; top:885px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">#102 - 32475 Simon Ave.</span>
<span name="Site12City" class="noborder" style="position:absolute; left:505px; top:900px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Abbotsford-Clearbrook</span>
<span name="Site12Phone" class="noborder" style="position:absolute; left:505px; top:915px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Phone 604-855-0112</span>
<span name="Site12Fax" class="noborder" style="position:absolute; left:505px; top:930px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">Fax 604-855-0109</span>
<span name="Site12Services" class="noborder" style="position:absolute; left:505px; top:945px; width:200px; height:16px; font-family:sans-serif; font-style:normal; font-size:12px; text-align:left; background-color:transparent;">UX M-F 8:00-5:00</span>
</div>

<div class="DoNotPrint" id="BottomButtons" style="position:absolute; left:5px; top:1000px;"		<table>
		<tr><td>
		<input name="newForm" id="newForm" type="hidden" value="True" />				
		Subject: <input name="subject" size="40" type="text"> 
		<input value="Submit" name="SubmitButton" id="SubmitButton" type="button" onclick="releaseDirtyFlag(); javascript:submission();"> 			
		<input value="Reset" name="ResetButton" id="ResetButton" type="reset"> 
		<input value="Print" name="PrintButton" id="PrintButton" type="button" onclick="printLetter();"> 			
		<input value="Print & Submit" name="PrintSubmitButton" id="PrintSubmitButton" type="button" onclick="printSubmit();">
		</td></tr>
		</table>
</div>
</form>


<!-- -----------Pop-up menu items ------------------------ -->
<!-- -----------Floating Box u0096 Part 2u0097(put this inbetween <body></body>)----------------- -->
<!-------------Floating Menu Items---------------->

<div id="topbar" class="DoNotPrint">
<form name="LazySelect">

<b>TYPE OF PROCEDURES:</b><br>
<u>Modality:</u><br>
	<!-- ----------Modality--------------->
	<input name="Xray" type="checkbox"
	onClick="
		document.FormName.ExamRequestedText.value+= 'X-ray ';
	">X-ray
	<input name="US" type="checkbox"
	onClick="
		document.FormName.ExamRequestedText.value+= 'Ultrasound ';
	">Ultrasound
<br>
	<input name="BariumEnema" type="checkbox"
	onClick="
		document.FormName.ExamRequestedText.value+= 'Barium Enema ';
	">Barium Enema
	<input name="ES&D" type="checkbox"
	onClick="
		document.FormName.ExamRequestedText.value+= 'ES&D ';
	">ES&D
<br>

	<input name="Routine 18 week Obstetrical US" type="checkbox"
	onClick="
		document.FormName.ExamRequestedText.value+= 'Routine 18 week Obstetrical Ultrasound';
                document.FormName.RelevantHistoryText.value+= 'Patient is pregnant and from her LMP she will be 18 WEEKS on           Please do the ultrasound on or around this date. Thank you.';
	">Routine 18 week Obstetrical US

<br>

<u>Side:</u><br>
	<!-- ----------Side------------------>
	<input name="Left" type="checkbox"
	onClick="
		document.FormName.ExamRequestedText.value+= 'left ';
	">Left
	<input name="Right" type="checkbox"
	onClick="
		document.FormName.ExamRequestedText.value+= 'right ';
	">Right
	<input name="bilateral" type="checkbox"
	onClick="
		document.FormName.ExamRequestedText.value+= 'bilateral ';
	">Bilateral<br>
	
<u>Body Part(s):</u><br>
	<!-- ---------Body Part------------->
	<input name="Head" type="checkbox"
	onClick="
		document.FormName.ExamRequestedText.value+= 'head ';
	">Head
	<input name="Sinuses" type="checkbox"
	onClick="
		document.FormName.ExamRequestedText.value+= 'sinuses ';
	">Sinuses
<br>
	<input name="Chest" type="checkbox"
	onClick="
		document.FormName.ExamRequestedText.value+= 'chest ';
	">Chest
	<input name="Abdomen" type="checkbox"
	onClick="
		document.FormName.ExamRequestedText.value+= 'abdomen ';
	">Abdomen
	<input name="Pelvis" type="checkbox"
	onClick="
		document.FormName.ExamRequestedText.value+= 'pelvis ';
	">Pelvis
<br>
	<input name="cspine" type="checkbox"
	onClick="
		document.FormName.ExamRequestedText.value+= 'C-spine ';
	">C-spine
	<input name="Tspine" type="checkbox"
	onClick="
		document.FormName.ExamRequestedText.value+= 'T-spine ';
	">T-spine
	<input name="Lspine" type="checkbox"
	onClick="
		document.FormName.ExamRequestedText.value+= 'L-spine ';
	">L-spine
<br>
	<input name="Shoulder" type="checkbox"
	onClick="
		document.FormName.ExamRequestedText.value+= 'shoulder ';
	">Shoulder
	<input name="Humerus" type="checkbox"
	onClick="
		document.FormName.ExamRequestedText.value+= 'humerus ';
	">Humerus
<br>
	<input name="Elbow" type="checkbox"
	onClick="
		document.FormName.ExamRequestedText.value+= 'elbow ';
	">Elbow
	<input name="forearm" type="checkbox"
	onClick="
		document.FormName.ExamRequestedText.value+= 'forearm ';
	">Forearm
<br>
	<input name="Wrist" type="checkbox"
	onClick="
		document.FormName.ExamRequestedText.value+= 'wrist ';
	">Wrist
	<input name="Scaphoid" type="checkbox"

	onClick="
		document.FormName.ExamRequestedText.value+= 'scaphoid ';
	">Scaphoid
	<input name="Hand" type="checkbox"
	onClick="
		document.FormName.ExamRequestedText.value+= 'hand ';
	">Hand
<br>
	<input name="Hip" type="checkbox"
	onClick="
		document.FormName.ExamRequestedText.value+= 'hip ';
	">Hip
	<input name="femur" type="checkbox"
	onClick="
		document.FormName.ExamRequestedText.value+= 'femur ';
	">Femur
	<input name="knee" type="checkbox"
	onClick="
		document.FormName.ExamRequestedText.value+= 'knee ';
	">Knee
<br>
	<input name="LowerLeg" type="checkbox"
	onClick="
		document.FormName.ExamRequestedText.value+= 'lower leg ';
	">Lower leg
	<input name="ankle" type="checkbox"
	onClick="
		document.FormName.ExamRequestedText.value+= 'ankle ';
	">Ankle
	<input name="Foot" type="checkbox"
	onClick="
		document.FormName.ExamRequestedText.value+= 'foot ';
	">Foot
<br>
<br>
<!-- ---------PATIENT INSTRUCTIONS------------->
<b>PATIENT INSTRUCTIONS:</b>
<br>
	<input type="checkbox" name="PatientToBook"
	 onClick="
		document.FormName.Appt.value =  'Patient will book appt';
	">Patient to book<br>

<u>X-ray:</u><br>

	<input type="checkbox" name="UGI,esophagus,smallbowel"
	 onClick="
		document.FormName.PtInstructions.value =  'Nothing to eat or drink after midnight the night before your appointment, which includes chewing gum, candies and smoking ';
	">UGI, esophagus, small bowel<br>

	<input type="checkbox" name="Colon"
	 onClick="
		document.FormName.PtInstructions.value = '48 hrs before appointment, you may have light lunch and dinner.  24 hrs before appointment, you may have clear fluids only. The day before appointment:  4:00pm--Drink entire contents of a Citromag solution with a large glass of water (or take 60 ml of castor oil at 10am).  5:00pm--Take 2 Dulcolax tablets with a large glass of water.  10:00pm--Insert one Dulcolax suppository.  You may take prescription medications with water up until your appointment time. A clean colon avoids need for repeat exam.';
	">Ba enema<br>

	<input type="checkbox" name="Hysterosalpingogram"
	 onClick="
		document.FormName.PtInstructions.value = 'Abstain from sexual intercourse from the first day of menstrual period until the examination has been completed.  Examination time is approx. 30 min. ';
	">Hysterosalpingogram<br>

<!----------Ultrasound-------------------->
<u>Ultrasound:</u><br>
	<input type="checkbox" name="Abdominal"
	 onClick="
		document.FormName.PtInstructions.value = 'Fasting for 12 hours prior to the test and fat free diet (no dairy products, meat, eggs or fried foods) for 24 hours (day before).  Nothing by mouth until after examination.  Examination time is approx 30 min.';
	">Abdominal

	<input type="checkbox" name="Renal Only"
	 onClick="
		document.FormName.PtInstructions.value = 'Drink 2 full glasses (16 oz.) of water 2 hours prior to examination.  Do not void until after the examination ';
	">Renal Only<br>
	<input type="checkbox" name="Pelvic/Obstetrical/Bladder examination"
	 onClick="
		document.FormName.PtInstructions.value = 'A full bladder is essential for these examinations.  Do not empty your bladder for 2 hours before your appointment.  Drink 32oz (4 cups) of any liquid, except milk.  Please complete drinking your fluids at least 1 hour before your appointment time.';
	">Pelvic-Obstetrical-Bladder exam<br>
	<input type="checkbox" name="Abdominal/Pelvic(Combination scan)"
	 onClick="
		document.FormName.PtInstructions.value = 'Fat free diet (no dairy products, meat, eggs or fried foods) for 24 hours and fasting for 12 hours.  Do not empty your bladder for 2 hours before your appointment.  Drink 32 oz. (4 cups) of any liquid, except milk.  Please complete drinking your fluids at least 1 hour before your appointment time.';
	">Abdo-pelvic combination scan<br>

<!------Mammogram--------------------->
<u>Mammogram:</u><br>
	<input type="checkbox" name="Mammogram"
	 onClick="
		document.FormName.PtInstructions.value = 'Do not use deodorant, anti-perspirant or talcum powder before the examination.  Stay on a caffeine-free diet to minimize discomfort of compression required for optimal examination.  If you are experiencing premenstrual breast tenderness, you may delay booking until tenderness has subsided.  Wear a two-piece outfit.  At time of booking, advise where previous mammogram was done and if possible, allow appropriate time for films to arrive before appointment date.  Exam is approx. 30-60 min. ';
	">Mammogram<br>

<!--------BMD--------------->
<u>BMD:</u><br>

	<input type="checkbox" name="BoneMineralDensity"
	 onClick="
		document.FormName.PtInstructions.value = 'Patients are asked to wear pants without zipper or metal attachments.';
	">BoneMineralDensity<br>

	<input value="Reset" name="reset" type="reset" onClick ="javascript: ClearInstructions()">
	<input value="Close" name="Close" type="button" onClick="javascript: closebar(); return false">
<br>
U = Ultrasound<br>
X = X-ray<br>
M = Mammography<br>
F = Fluoroscopy<br>
B = BMD<br>
H = Hysterosalpingogram
</form></div>
<!--  -----------Pop-up end----------------------- -->

</body></html>

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