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Fraser Health Community Mental Health Referral Form HTML

HTML icon CommunityMentalHealthReferral.html — HTML, 44 kB (45696 bytes)

File contents

<html>
<head>

	<link rel="stylesheet" type="text/css" media="print" href="${oscar_image_path}JSMPC.css" />
	<!--<script language="javascript" type="text/javascript" media="print" src="${oscar_image_path}JSMPC.js"></script>	-->
	
<style type="text/css" media="print">
 .DoNotPrint {
	 display:none;
 }
 .noborder {
	 border :0px;
	 background:transparent;
	 scrollbar-3dlight-color:transparent;
	 scrollbar-3dlight-color:transparent;
	 scrollbar-arrow-color:transparent;
	 scrollbar-base-color:transparent;
	 scrollbar-darkshadow-color:transparent;
	 scrollbar-face-color:transparent;
	 scrollbar-highlight-color:transparent;
	 scrollbar-shadow-color:transparent;
	 scrollbar-track-color:transparent;
	 background:transparent;
	 overflow:hidden;
 }
 </style>

<script language="javascript" type="text/javascript">
	/****************************
	startup functions 
	****************************/
	function startUp()
	{			
		// shows the forms on development machine from notepad ++ - saves you from uploading to the server to input alignments
		var strLoc = window.location.href.toLowerCase();
		if(strLoc.indexOf("https") == -1)
		{
			//page1
			var src = document.getElementById('BGImage').src;				
			document.getElementById('BGImage').src = src.replace('$%7Boscar_image_path%7D','');
			// page2
			var src2 = document.getElementById('BGImage2').src;
			document.getElementById('BGImage2').src = src2.replace('$%7Boscar_image_path%7D','');
		}
		setDocumentTitle('Community Mental Health Referral',document.getElementById('Pg1Surname').value);
	}
	
	function setDocumentTitle(Title,Pg1Surname)
	{
		// set document title
		document.title = Title + ' - ' + Pg1Surname;					
						
	}


	/****************************
		submit and print functions 
	****************************/
	function printSubmit()
	{
		printLetter();
		releaseDirtyFlag();			
		submission();
	}
		function printLetter(){
		// hide the bottom buttons
		if (document.getElementById('BottomButtons').style.display == '')
			document.getElementById('BottomButtons').style.display = 'none';
		// print the letter
		window.print();
	} 

	function submission()
	{
		setFlag();
		setTimeout('document.FormName.submit()',1000);			
	}
		function setFlag()
	{
		// indicate that the form has been submitted
		if (document.getElementById("newForm").value == 'True')
			document.getElementById("newForm").value = 'False';
	}
		
	function showButtons()
	{
		//show the bottom buttons if they are hidden
		if (document.getElementById('BottomButtons').style.display == 'none')
			document.getElementById('BottomButtons').style.display = '';
	}

	/****************************
		checkbox functions 
	****************************/
	function changeValue(x)
	{
		if (document.getElementById(x).value == '')
			document.getElementById(x).value = 'X';
		else
			document.getElementById(x).value = '';
	}

	function displayKeyCode(evt,x)
	{
		var charCode = (evt.which) ? evt.which : event.keyCode
		// any key press except tab will constitute a value change to the checkbox
		if (charCode != 9)
		{
			changeValue(x);
			return false;
		}
	}
</script>

<!-------Script to optimize window on loading----------->
<script language="JavaScript">
	top.window.moveTo(0,0);
	if (document.all)
	{
		top.window.resizeTo(screen.availWidth,screen.availHeight);
	}
	else if (document.layers||document.getElementById)
	{
	if (top.window.outerHeight<screen.availHeight||top.window.outerWidth<screen.availWidth)
	{
	top.window.outerHeight = screen.availHeight;
	top.window.outerWidth = 875;
	}
	}
</script>
<!----------End optimize window script---------->

<!-- scripts to confirm closing of window if haven't saved yet -->
<script language="javascript">
	//keypress events trigger dirty flag
	var needToConfirm = true;
	document.onkeyup=setDirtyFlag;
	function setDirtyFlag()
	{
	needToConfirm = true;
	}
	function releaseDirtyFlag()
	{
	needToConfirm = false; //Call this function if doesn't requires an alert.
	//this could be called when save button is clicked
	}
	window.onbeforeunload = confirmExit;
	function confirmExit()
	{
	if (needToConfirm)
	{
	return "You have attempted to leave this page. If you have made any changes to the fields without clicking the Save button, your changes will be lost. Are you sure you want to exit this page?";
	}
	}
</script>

<!-- Pre-checking Gender script -->
<script type="text/javascript" language="javascript">
function checkGender(){
	if (document.getElementById('PatientGender').value == 'M'){
		document.getElementById('Pg1Male').value = 'X';
	}else if (document.getElementById('PatientGender').value == 'F'){
		document.getElementById('Pg1Female').value = 'X';
	}
}
</script>
</head>

<!------------------------
2013-02-11
X-box------------------>


<body onload="startUp(); checkGender();" onMouseDown="showButtons();">
<form method="post" action="" name="FormName" id="FormName" >

<div id="page1" style="position:relative; left:0px; top:0px; width:750px;" class="pagebreak">
	<img id="BGImage" src="${oscar_image_path}MHSU1.png" width="750">	


<textarea name="Pg1MentalHealthClinicName" id="Pg1MentalHealthClinicName"  type="text" class="noborder" style="position:absolute; left:120px; top:6px; width:265px; height:22px; font-family:Times New Roman; font-size:14px; font-weight:bold; text-align:left; background-color:transparent;"></textarea>	
<textarea name="Pg1MentalHealthAddress" id="Pg1MentalHealthAddress"  type="text" class="noborder" style="position:absolute; left:120px; top:28px; width:480px; height:22px; font-family:Times New Roman; font-size:14px; font-weight:bold; text-align:left; background-color:transparent;"></textarea>	
<textarea name="Pg1MentalHealthNo" id="Pg1MentalHealthFaxNo"  type="text" class="noborder" style="position:absolute; left:120px; top:50px; width:480; height:22px; font-family:Times New Roman; font-size:18px; font-weight:bold; text-align:left; background-color:transparent;"></textarea>	

<select style="position:absolute; left:385px; top:8px; width:215px;  background-color:#F78181; " class="DoNotPrint">
<option onClick="document.FormName.Pg1MentalHealthClinicName.value = ''; document.FormName.Pg1MentalHealthAddress.value = '';  document.FormName.Pg1MentalHealthNo.value = '';">Select Mental Health Clinic	
<option onClick="document.FormName.Pg1MentalHealthClinicName.value = 'Tri-Cities Mental Health Center';  document.FormName.Pg1MentalHealthAddress.value = '2232 Elgin Avenue, Port Coquitlam, British Columbia, V3C 2B2';  document.FormName.Pg1MentalHealthNo.value = 'Phone #: 604-777-8400     Fax #: 604-777-8411';">Tri-Cities	
<option onClick="document.FormName.Pg1MentalHealthClinicName.value = 'Maple Ridge Mental Health Center';  document.FormName.Pg1MentalHealthAddress.value = '22470 Dewdney Trunk Road, Maple Ridge, British Columbia, V2X 5Z6';  document.FormName.Pg1MentalHealthNo.value = 'Phone #: 604-476-7165     Fax #: 604-476-7199';">Maple Ridge
<option onClick="document.FormName.Pg1MentalHealthClinicName.value = 'New Westminster Mental Health Center';  document.FormName.Pg1MentalHealthAddress.value = '403 - 6th Street, New Westminster, British Columbia, V3L 3B1';  document.FormName.Pg1MentalHealthNo.value = 'Phone #: 604-777-6800     Fax #: 604-522-6223';">New Westminster
<option onClick="document.FormName.Pg1MentalHealthClinicName.value = 'Burnaby Mental Health Center';  document.FormName.Pg1MentalHealthAddress.value = '3935 Kincaid Street, Burnaby, British Columbia, V5G 2X6';  document.FormName.Pg1MentalHealthNo.value = 'Phone #: 604-453-1900     Fax #: 604-453-1929';">Burnaby
<option onClick="document.FormName.Pg1MentalHealthClinicName.value = 'Surrey Mental Health Center';  document.FormName.Pg1MentalHealthAddress.value = '13401 - 108th Avenue, 11th Floor, Surrey, British Columbia, V3T 5T3';  document.FormName.Pg1MentalHealthNo.value = 'Phone #: 604-953-4900     Fax #: 604-953-4901';">Surrey
<option onClick="document.FormName.Pg1MentalHealthClinicName.value = 'Langley Mental Health Center';  document.FormName.Pg1MentalHealthAddress.value = '20300 Fraser Highway, Langley, British Columbia, V3A 4E6';  document.FormName.Pg1MentalHealthNo.value = 'Phone #: 604-5147940     Fax #: 604-534-6817';">Langley
</select>


		
<input name="Pg1Title" id="Pg1Title" type="text" class="noborder" style="position:absolute; left:93px; top:222px; width:197px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Pg1Surname" id="Pg1Surname" type="text" class="noborder" style="position:absolute; left:122px; top:248px; width:276px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=patient_nameL>


<input name="Pg1FirstName" id="Pg1FirstName" type="text" class="noborder" style="position:absolute; left:122px; top:275px; width:276px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=patient_nameF>


<input name="Pg1MiddleName" id="Pg1MiddleName" type="text" class="noborder" style="position:absolute; left:122px; top:302px; width:276px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Pg1PreferredName" id="Pg1PreferredName" type="text" class="noborder" style="position:absolute; left:113px; top:327px; width:117px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Pg1PrefSurname" id="Pg1PrefSurname" type="text" class="noborder" style="position:absolute; left:289px; top:327px; width:109px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Pg1Address1" id="Pg1Address1" type="text" class="noborder" style="position:absolute; left:411px; top:248px; width:239px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=address_street_number_and_name>


<input name="Pg1City" id="Pg1City" type="text" class="noborder" style="position:absolute; left:439px; top:275px; width:131px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=city>


<input name="Pg1Province" id="Pg1Province" type="text" class="noborder" style="position:absolute; left:631px; top:275px; width:105px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=province>


<input name="Pg1PostalCode" id="Pg1PostalCode" type="text" class="noborder" style="position:absolute; left:449px; top:302px; width:121px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=postal>


<input name="Pg1Country" id="Pg1Country" type="text" class="noborder" style="position:absolute; left:625px; top:302px; width:111px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Pg1PHN" id="Pg1PHN" type="text" class="noborder" style="position:absolute; left:613px; top:327px; width:123px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=hin>


<input name="Pg1DOB" id="Pg1DOB" type="text" class="noborder" style="position:absolute; left:119px; top:354px; width:109px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=dobc>


<input name="Pg1Age" id="Pg1Age" type="text" class="noborder" style="position:absolute; left:363px; top:354px; width:42px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=age>


<input name="Pg1NFA" id="Pg1NFA" type="text" style="position:absolute; left:655px; top:225px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg1Homeless" id="Pg1Homeless" type="text" style="position:absolute; left:655px; top:252px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg1CurrentAddress" id="Pg1CurrentAddress" type="text" style="position:absolute; left:409px; top:323px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg1DoNotMail" id="Pg1DoNotMail" type="text" style="position:absolute; left:409px; top:337px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg1AgeEstimated" id="Pg1AgeEstimated" type="text" style="position:absolute; left:299px; top:363px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg1SexUnknown" id="Pg1SexUnknown" type="text" style="position:absolute; left:590px; top:363px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg1HomePhone" id="Pg1HomePhone" type="text" class="noborder" style="position:absolute; left:183px; top:380px; width:152px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=phone>


<input name="Pg1HomePrimary" id="Pg1HomePrimary" type="text" style="position:absolute; left:338px; top:378px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg1HomeMsgYes" id="Pg1HomeMsgYes" type="text" style="position:absolute; left:649px; top:389px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg1HomeMsgNo" id="Pg1HomeMsgNo" type="text" style="position:absolute; left:697px; top:389px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg1NoPhone" id="Pg1NoPhone" type="text" style="position:absolute; left:50px; top:397px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg1OtherPhone" id="Pg1OtherPhone" type="text" class="noborder" style="position:absolute; left:183px; top:409px; width:149px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=cell>


<input name="Pg1OtherPrimary" id="Pg1OtherPrimary" type="text" style="position:absolute; left:339px; top:404px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg1OtherMsgYes" id="Pg1OtherMsgYes" type="text" style="position:absolute; left:648px; top:415px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg1OtherMsgNo" id="Pg1OtherMsgNo" type="text" style="position:absolute; left:697px; top:415px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg1NofKName" id="Pg1NofKName" type="text" class="noborder" style="position:absolute; left:183px; top:434px; width:173px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Pg1NoKRelation" id="Pg1NoKRelation" type="text" class="noborder" style="position:absolute; left:439px; top:434px; width:87px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Pg1NoKPhone" id="Pg1NoKPhone" type="text" class="noborder" style="position:absolute; left:637px; top:434px; width:99px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Pg1NoKMsg" id="Pg1NoKMsg" type="text" style="position:absolute; left:531px; top:441px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg1FirstContact" id="Pg1FirstContact" type="text" style="position:absolute; left:50px; top:466px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg1FirstContactName1" id="Pg1FirstContactName1" type="text" class="noborder" style="position:absolute; left:222px; top:459px; width:135px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Pg1FirstContactRelation" id="Pg1FirstContactRelation" type="text" class="noborder" style="position:absolute; left:439px; top:459px; width:85px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Pg1FirstContactPhone" id="Pg1FirstContactPhone" type="text" class="noborder" style="position:absolute; left:637px; top:459px; width:99px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Pg1FirstContactMsg" id="Pg1FirstContactMsg" type="text" style="position:absolute; left:530px; top:468px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg1GP" id="Pg1GP" type="text" class="noborder" style="position:absolute; left:164px; top:496px; width:233px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=doctor>


<input name="Pg1GPPhone" id="Pg1GPPhone" type="text" class="noborder" style="position:absolute; left:456px; top:496px; width:130px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=clinic_phone>


<input name="Pg1GPFax" id="Pg1GPFax" type="text" class="noborder" style="position:absolute; left:629px; top:496px; width:105px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=clinic_fax>


<input name="Pg1GPNone" id="Pg1GPNone" type="text" style="position:absolute; left:50px; top:491px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg1CCGP" id="Pg1CCGP" type="text" style="position:absolute; left:50px; top:504px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg1NoPsych" id="Pg1NoPsych" type="text" style="position:absolute; left:50px; top:529px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg1PsychiatristName" id="Pg1PsychiatristName" type="text" class="noborder" style="position:absolute; left:128px; top:521px; width:269px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Pg1PsychPhone" id="Pg1PsychPhone" type="text" class="noborder" style="position:absolute; left:456px; top:521px; width:130px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Pg1PsychFax" id="Pg1PsychFax" type="text" class="noborder" style="position:absolute; left:629px; top:521px; width:105px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Pg1Priority1" id="Pg1Priority1" type="text" style="position:absolute; left:106px; top:589px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg1Priority2" id="Pg1Priority2" type="text" style="position:absolute; left:177px; top:589px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg1Priority3" id="Pg1Priority3" type="text" style="position:absolute; left:265px; top:589px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg1Priority4" id="Pg1Priority4" type="text" style="position:absolute; left:338px; top:589px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<textarea name="Pg1ReferrralReason" id="Pg1ReferrralReason" class="noborder" style="position:absolute; left:52px; top:647px; width:684px; height:78px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" onblur="subject.value=Pg1ReferrralReason.value;" ></textarea>


<textarea name="Pg1ServicesRequested" id="Pg1ServicesRequested" class="noborder" style="position:absolute; left:52px; top:742px; width:684px; height:56px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" ></textarea>


<textarea name="Pg1CurrentDiagnosis" id="Pg1CurrentDiagnosis" class="noborder" style="position:absolute; left:52px; top:816px; width:684px; height:58px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=medical_history></textarea>


<input name="Pg1ClientAwareYes" id="Pg1ClientAwareYes" type="text" style="position:absolute; left:212px; top:878px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg1ClientAwareNo" id="Pg1ClientAwareNo" type="text" style="position:absolute; left:263px; top:878px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg1FamilyAwareYes" id="Pg1FamilyAwareYes" type="text" style="position:absolute; left:545px; top:878px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg1ClientAwareNo" id="Pg1ClientAwareNo" type="text" style="position:absolute; left:596px; top:878px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg1DischargeDate" id="Pg1DischargeDate" type="text" class="noborder" style="position:absolute; left:452px; top:901px; width:284px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Pg1Extended LeaveNo" id="Pg1Extended LeaveNo" type="text" style="position:absolute; left:105px; top:938px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg1ExtendedLeaveYes" id="Pg1ExtendedLeaveYes" type="text" style="position:absolute; left:147px; top:938px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg1CertificateExpiry" id="Pg1CertificateExpiry" type="text" class="noborder" style="position:absolute; left:365px; top:930px; width:111px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Pg1AcceptingMRP" id="Pg1AcceptingMRP" type="text" class="noborder" style="position:absolute; left:540px; top:930px; width:196px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Pg1MHSUContact" id="Pg1MHSUContact" type="text" class="noborder" style="position:absolute; left:373px; top:958px; width:42px; height:23px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Pg1MHSUNA" id="Pg1MHSUNA" type="text" style="position:absolute; left:418px; top:956px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg1MHSUUnknown" id="Pg1MHSUUnknown" type="text" style="position:absolute; left:418px; top:969px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg1EmergContact" id="Pg1EmergContact" type="text" class="noborder" style="position:absolute; left:613px; top:959px; width:42px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Pg1EmergContactNA" id="Pg1EmergContactNA" type="text" style="position:absolute; left:661px; top:956px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg1EmergContactUnknown" id="Pg1EmergContactUnknown" type="text" style="position:absolute; left:661px; top:969px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="PatientGender" id="PatientGender" type="hidden" oscarDB=sex>
<input name="Pg1Male" id="Pg1Male" type="text" class="noborder" style="position:absolute; left: 469px; top: 363px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="Pg1Female" id="Pg1Female" type="text" class="noborder" style="position:absolute; left: 520px; top: 363px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
	

</div>
<!-- -----------------End of Page 1----------------------------------------------- -->

<div id="page2" style="position:relative;" class="pagebreak">
	<img id="BGImage2" src="${oscar_image_path}MHSU2.png" width="750">
	
	
<input name="Pg2PatientNameL" id="Pg2PatientNameL" type='text' class="noborder" style="position:absolute; left:488px; top:52px; width:248px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=patient_nameL>

<input name="Pg2PatientNameF" id="Pg2PatientNameF" type='text'class="noborder" style="position:absolute; left:488px; top:76px; width:248px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=patient_nameF>


<input name="Pg2ReferralSource" id="Pg2ReferralSource" type="text" class="noborder" style="position:absolute; left:85px; top:162px; width:285px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Pg2ReferralDate" id="Pg2ReferralDate" type="text" class="noborder" style="position:absolute; left:482px; top:162px; width:254px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=today>


<input name="Pg2Title" id="Pg2Title" type="text" class="noborder" style="position:absolute; left:85px; top:189px; width:285px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Pg2Role" id="Pg2Role" type="text" class="noborder" style="position:absolute; left:482px; top:189px; width:254px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Pg2ReferralName" id="Pg2ReferralName" type="text" class="noborder" style="position:absolute; left:100px; top:217px; width:270px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=current_user>


<input name="Pg2ClinicPhone" id="Pg2ClinicPhone" type="text" class="noborder" style="position:absolute; left:482px; top:217px; width:254px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=clinic_phone>


<input name="Pg2ClinicName" id="Pg2ClinicName" type="text" class="noborder" style="position:absolute; left:100px; top:243px; width:270px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=clinic_name>


<input name="Pg2ReferenceNumber" id="Pg2ReferenceNumber" type="text" class="noborder" style="position:absolute; left:482px; top:243px; width:254px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<textarea name="Pg2Medications" id="Pg2Medications" class="noborder" style="position:absolute; left:32px; top:355px; width:704px; height:144px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=recent_rx></textarea>


<input name="Pg2MAR" id="Pg2MAR" type="text" style="position:absolute; left:336px; top:328px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg2CurrentRx" id="Pg2CurrentRx" type="text" style="position:absolute; left:435px; top:328px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg2Pharmanet" id="Pg2Pharmanet" type="text" style="position:absolute; left:587px; top:328px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg2LAMedName" id="Pg2LAMedName" type="text" class="noborder" style="position:absolute; left:157px; top:503px; width:170px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Pg2LADosage" id="Pg2LADosage" type="text" class="noborder" style="position:absolute; left:384px; top:503px; width:151px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Pg2LAFrequency" id="Pg2LAFrequency" type="text" class="noborder" style="position:absolute; left:605px; top:503px; width:131px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Pg2LALastDose" id="Pg2LALastDose" type="text" class="noborder" style="position:absolute; left:279px; top:532px; width:152px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Pg2LANextDue" id="Pg2LANextDue" type="text" class="noborder" style="position:absolute; left:596px; top:532px; width:140px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Pg2MedAdNAI" id="Pg2MedAdNAI" type="text" style="position:absolute; left:175px; top:565px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg2MedADUnknown" id="Pg2MedADUnknown" type="text" style="position:absolute; left:273px; top:565px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg2MedAdComplianceIssues" id="Pg2MedAdComplianceIssues" type="text" style="position:absolute; left:359px; top:565px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg2MedAdSpecify" id="Pg2MedAdSpecify" type="text" class="noborder" style="position:absolute; left:564px; top:561px; width:172px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Pg2MedSelf" id="Pg2MedSelf" type="text" style="position:absolute; left:174px; top:594px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg2MedPlanG" id="Pg2MedPlanG" type="text" style="position:absolute; left:243px; top:594px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg2MedOther" id="Pg2MedOther" type="text" style="position:absolute; left:324px; top:594px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Pg2MedSpecify" id="Pg2MedSpecify" type="text" class="noborder" style="position:absolute; left:460px; top:590px; width:276px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Pg2AllergyProfile" id="Pg2AllergyProfile" type="text" style="position:absolute; left:579px; top:622px; width:11px; height:11px; border:1px solid #000000;font-weight:bold; font-size:9px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<textarea name="Pg2Allergy" id="Pg2Allergy"  class="noborder" style="position:absolute; left:32px; top:638px; width:704px; height:338px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=allergies_des_no_archived></textarea>

</div>
<!-- -----------------End of Page 2----------------------------------------------- -->

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<div class="DoNotPrint" id="BottomButtons">
	<table><tr><td>
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				<input value="Submit" name="SubmitButton" id="SubmitButton" type="button" onclick="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>
</body>
</html>

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