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Speech and Language Referral

Speech and Language referral - Fraser Health --- Hi JohnY, I have updated your form to add a drop down list of the Health Units and address/phone/fax numbers. Uses the same image Herb.

HTML icon SLP-Referral-X-boxV2.html — HTML, 21 kB (21633 bytes)

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<html>
<head>
<!---------Created 2012-02 by John Yap.   X-boxed. ----------------------------------------->
<!---------Updated 2013-06 by Herb Chang to add address drop-down list for Health Units----->


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</head>
<body onload="startUp();" onMouseDown="showButtons();">

<form method="post" action="" name="FormName" id="FormName" >

<div id="page1" style="position:relative; left:0px; top:20px; width:750px;" class="pagebreak">
	<img id="BGImage" SRC="${oscar_image_path}SLP_referral.png" width:750px">

<textarea name="SLPClinic" class="noborder" style="position:absolute; left:200px; top:00px; width:350px; height:85px; font-family:sans-serif; font-size:16px; font-weight:bold; background-color:transparent;"></textarea>
<!-- ---------------SLPClinic Drop-down list----------------------------- -->
<select class="DoNotPrint" style="position:absolute; left:555px; top:00px; background-color:#F6CECE; ">
	<option onClick="document.FormName.SLPClinic.value = ''">choose Health Unit</option>
	<option onClick="document.FormName.SLPClinic.value = 'Port Moody Health Unit \n#200 - 205 Newport Drive \nPort Moody, BC &nbsp V3H 5C9 \nPhone: 604-949-7210 &nbsp Fax: 604-949-7211 '">Port Moody</option>
	<option onClick="document.FormName.SLPClinic.value = 'Port Coquitlam Health Unit \n2266 Wilson Avenue \nPort Coquitlam, BC &nbsp V3C 1Z5 \nPhone: 604-777-8703  &nbsp Fax: 604-941-2409 '">Port Coquitlam</option>
	<option onClick="document.FormName.SLPClinic.value = 'New Westminster Health Unit \n#105 - 80A - Sixth Street \nNew Westminster, BC &nbsp V3L 5B3 \nPhone: 604-777-6855 &nbsp Fax: 604-525-3803 '">New Westminster</option>
	<option onClick="document.FormName.SLPClinic.value = 'Maple Ridge Health Unit \n#400 - 22470 Dewdney Trunk Road \nMaple Ridge, BC &nbsp V2X 5Z6 \nPhone: 604-476-7000 &nbsp Fax: 604-476-7077 '">Maple Ridge</option>
	<option onClick="document.FormName.SLPClinic.value = 'Burnaby Health Unit \n#105 - 4946 Canada Way \nBurnaby, BC &nbsp V5G 4H7 \nPhone: 604-918-7663 &nbsp Fax: 604-918-7660 '">Burnaby</option>
	<option onClick="document.FormName.SLPClinic.value = ''">blank</option>
</select>

<!-- ---------------PATIENT INFO----------------------------- -->
<input name="Name" id="Name" type="text" class="noborder" style="position:absolute; left:10px; top:196px; width:350px; font-family:Arial; font-size:16px; background-color:transparent; background-color:transparent;" oscarDB=patient_name>
<input name="gender" type="text" oscardb=sex style="position:absolute; left:405px; top:196px; width:40px; font-family:Arial; font-size:16px; font-weight:bold; text-align:center; background-color:transparent;" class="noborder">
<input name="TodaysDate" id="TodaysDate" type="text" class="noborder" style="position:absolute; left:500px; top:196px; width:200px; font-family:Arial; font-size:16px; text-align:left; background-color:transparent;" oscardb=today>

<input name="Language" type="text" class="noborder" style="position: absolute; left:180px; top:230px; width:100px; font-family:Arial; font-size:14px; text-align:left; background-color:transparent;" value="">
	
<textarea name="Aboriginal" style="position: absolute; left:425px; top:230px; width:45px; height:20px; font-family: Arial; font-size: 14px; font-weight: bold;" class="noborder"></textarea>
<select style="position: absolute; left:475px; top:230px;" class="DoNotPrint">
	<option onClick="document.FormName.Aboriginal.value = ''"></option>
	<option onClick="document.FormName.Aboriginal.value = 'YES'">YES</option>	
	<option onClick="document.FormName.Aboriginal.value = 'NO'">NO</option>	
</select>

<input name="Patient_Address" type="text" class="noborder" style="position: absolute; left:10px; top:270px; width:450px; font-family:Arial; font-size:16px; text-align:left; background-color:transparent;" oscardb=addressLine>

<input name="PatientHomePhone" type="text" class="noborder" style="position:absolute; left:580px; top:250px; width:168px; font-family:Arial; font-size:16px; text-align:left; background-color:transparent;" oscardb=phone>
<input name="PatientWorkPhone" type="text" class="noborder" style="position:absolute; left:580px; top:285px; width:168px; font-family:Arial; font-size:16px; text-align:left; background-color:transparent;" oscardb=cell>

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<input name="PHN" id="PHN" type="text" class="noborder" style="position:absolute; left:308px; top:338px; width:150px; font-family:Arial; font-size:16px; text-align:center; background-color:transparent; background-color:transparent;" oscarDB=hinc>
<input name="PatientsDoctor" type="text" class="noborder" style="position:absolute; left:498px; top:338px; width:230px; font-family:Arial; font-size:16px; text-align:left; background-color:transparent;" oscardb=current_user>

<input name="IfMinor" type="text" class="noborder" style="position:absolute; left:10px; top:390px; width:280px; font-family:Arial; font-size:16px; text-align:left; background-color:transparent;">
<input name="SpouseContact" type="text" class="noborder" style="position:absolute; left:306px; top:390px; width:178px; font-family:Arial; font-size:16px; text-align:center; background-color:transparent;">

<input name="PreschoolEtc" type="text" class="noborder" style="position:absolute; left:10px; top:432px; width:280px; font-family:Arial; font-size:16px; text-align:left; background-color:transparent;">
<input name="TeacherGrade" type="text" class="noborder" style="position:absolute; left:306px; top:432px; width:178px; font-family:Arial; font-size:16px; text-align:center; background-color:transparent;">

<textarea name="ParentNotified" style="position: absolute; left:570px; top:418px; width:45px; height:20px; font-family: Arial; font-size:14px; font-weight:bold;" class="noborder"></textarea>
<select style="position: absolute; left:620px; top:418px;" class="DoNotPrint">
	<option onClick="document.FormName.ParentNotified.value = ''"></option>
	<option onClick="document.FormName.ParentNotified.value = 'YES'">YES</option>	
	<option onClick="document.FormName.ParentNotified.value = 'NO'">NO</option>	
</select>

<!-- -----Problem------------------------ -->
<textarea name="Problem" class="noborder" style="position:absolute; left:10px; top:520px; width:425px; height:125px; font-family:Arial; font-style:normal; font-weight:normal; font-size:16px; text-align:left; background-color:transparent;"></textarea>

<!-- -----Audiological Services------------------------ -->
<input name="SwimMolds" id="SwimMolds" type="text" style="position:absolute; left:6px; top:677px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="HearingProtect" id="HearingProtect" type="text" style="position:absolute; left:236px; top:677px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="HearingEval" id="HearingEval" type="text" style="position:absolute; left:6px; top:705px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="EvalHearingAid" id="EvalHearingAid" type="text" style="position:absolute; left:236px; top:705px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">

<input name="BCCH" id="BCCH" type="text" style="position:absolute; left:461px; top:547px; width:12px; height:12px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="ENT" id="ENT" type="text" style="position:absolute; left:461px; top:563px; width:12px; height:12px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="Elks" id="Elks" type="text" style="position:absolute; left:461px; top:579px; width:12px; height:12px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="IDP" id="IDP" type="text" style="position:absolute; left:461px; top:594px; width:12px; height:12px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="Paed" id="Paed" type="text" style="position:absolute; left:461px; top:611px; width:12px; height:12px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="SHH" id="SHH" type="text" style="position:absolute; left:461px; top:627px; width:12px; height:12px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="SCCP" id="SCCP" type="text" style="position:absolute; left:461px; top:642px; width:12px; height:12px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="OtherGroup" id="OtherGroup" type="text" style="position:absolute; left:461px; top:673px; width:12px; height:12px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<textarea name="OtherGroupText" class="noborder" style="position:absolute; left:510px; top:668px; width:250px; height:50px; font-family:Arial; font-style:normal; font-weight:normal; font-size:16px; text-align:left; background-color:transparent;"></textarea>


<!-- ---------SignOff------------------------------- -->
<span style="position:absolute; left:120px; top:771px; font-size:18px; font-family:Arial; font-style:italic; font-weight:bold; ">"Electronically signed"</span>
<input name="PatientsDoctor" type="text" class="noborder" style="position:absolute; left:50px; top:824px; width:420px; font-family:Arial; font-size:16px; text-align:left; background-color:transparent;" oscardb=current_user>

<!-- ---------------CLINIC INFO----------------------------- -->
<input name="ClinicPhone" id="ClinicPhone" type="text" class="noborder" style="position:absolute; left:610px; top:824px; width:180px; font-family:Arial; font-size:16px; text-align:left; background-color:transparent;" oscardb=clinic_phone>
<input name="ClinicAddress" type="text" class="noborder" style="position:absolute; left:70px; top:857px; width:485px; font-family:Arial; font-size:16px; text-align:left; background-color:transparent;" oscardb=clinic_address>
<span style="position:absolute; left:570px; top:857px; font-size:14px;  font-family:Arial; font-size:14px; font-weight:bold; ">Fax: </span>
<input name="ClinicFax" id="ClinicFax" type="text" class="noborder" style="position:absolute; left:610px; top:857px; width:180px; font-family:Arial; font-size:16px; text-align:left; background-color:transparent;" oscardb=clinic_fax>

<!-- ---------------Referral Relationship----------------------------- -->
<input name="ParentGuardian" id="ParentGuardian" type="text" style="position:absolute; left:370px; top:887px; width:12px; height:12px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="Physician" id="Physician" type="text" style="position:absolute; left:517px; top:887px; width:12px; height:12px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="Audiologist" id="Audiologist" type="text" style="position:absolute; left:600px; top:887px; width:12px; height:12px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="PublicHealth" id="PublicHealth" type="text" style="position:absolute; left:370px; top:900px; width:12px; height:12px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="SLP" id="SLP" type="text" style="position:absolute; left:517px; top:900px; width:12px; height:12px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="OtherReferral" id="OtherReferral" type="text" style="position:absolute; left:370px; top:915px; width:12px; height:12px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="OtherReferralText" type="text" class="noborder" style="position:absolute; left:428px; top:910px; width:362px; font-family:Arial; font-style:normal; font-weight:normal; font-size:16px; text-align:left; background-color:transparent;" value="">

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</form>
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