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Referral form for Dr. Manbir Sandhu Surrey BC html file

HTML icon Dr Manbir Sandhu 2015 Referral form.html — HTML, 15 kB (15775 bytes)

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<html>
<head>
<META http-equiv="Content-Type" content="text/html; charset=UTF-8">
<title>Dr. Manbir Sandhu Referral form 2015</title>
<style>
 input {
	 -moz-box-sizing: content-box;
	 -webkit-print-color-adjust: exact;
	 -webkit-box-sizing: content-box;
	 box-sizing: content-box
}
 .sig {
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<style type="text/css" media="print">
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.sig {
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	 background-color: transparent;
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 </style>

<!-- jQuery file for testing outside of OSCAR -->
<script type="text/javascript" src="jquery-1.7.1.min.js"></script>
<script type="text/javascript" src="jSignature.min.js"></script>

<!-- OSCAR based files for greater functionality -->
<script type="text/javascript" src="${oscar_javascript_path}jquery/jquery-1.4.2.js"></script>
<!-- auto ticking gender Xboxes OR checkboxes -->
<script type="text/javascript" language="javascript">
function checkGender(){
	 if (document.getElementById("PatientGender").value == "M"){
	 document.getElementById("Male").value ="X";
	 }else if (document.getElementById("PatientGender").value == "F"){
	 document.getElementById("Female").value ="X";
	}
 }
</script>

<script language="javascript">
function formPrint(){
	window.print();
} 
</script>

<!-- scripts to confirm closing of window if it hadnt been saved yet -->
<script language="javascript">
//keypress events trigger dirty flag
var needToConfirm = false;
document.onkeyup=setDirtyFlag;
function setDirtyFlag(){
	needToConfirm = true;
}
function releaseDirtyFlag(){
	needToConfirm = false; //Call this function to prevent 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>


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	<!-- XBox styling -->
	
	<!-- XBox code -->
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<script type="text/javascript">
function reImg(){
// for stand alone development without uploading to OSCAR
	var strLoc = window.location.href.toLowerCase();
	if(strLoc.indexOf("https") == -1) {
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</head>

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

<span style="position:absolute; left:50px; top:50px; text-align:left; ">Referral Form for <b><u>Adults and Pediatrics</u></b></span>

<table colspan=3 style='position:absolute; left:550px; top:50px; border:.75pt solid black; background:transparent; text-align:left; width:300px; border-collapse: collapse;'>
   <tr>
	<td >Date of<br>Referral:</td>
	<td ><input name="Date" id="Date" type="text"   oscarDB=today ></td>
	<td  ><b>yyyy/mm/dd</b></td>
   </tr>
   <tr><td colspan=3 style='border:.75pt solid black; border-collapse: collapse;'>&nbsp;</td></tr>
   </table><br>
<table  style='position:absolute; left:0px; top:150px; width:750px; font-family:sans-serif; text-align:center;'>
   <tr>
	<td style=" font-weight:bold; font-size:16px;"><b>DR. MANBIR SANDHU</td>
   </tr>
   <tr>
	<td style=" font-weight:normal; font-size:12px;">Allergy, Asthma &amp; Immunology Specialist</td>
   </tr>
   <tr>
	<td style=" font-weight:normal; font-size:12px;">710-13737 96<sup>th</sup> Avenue, Surrey</td>
   </tr>
   <tr>
	<td style=" font-weight:normal; font-size:12px;">Tel:604-498-1655 Fax:604-498-1656</td>
   </tr>
   </table><br>


<table style='position:absolute; left:50px; top:250px; width:750px; font-family:sans-serif; font-size:12px; border:.75pt solid black; background:transparent; border-collapse: collapse;'>
   <tr>
	<th colspan=16 style='border:.75pt solid black;'>Patient Information (please print)</th>
   </tr>
   <tr>
	<td colspan=8 ><b>Name</b><i> (last, first, M.I.):</i><input name="PtName" id="PtName" type="text"  style=" width:200px;"  oscarDB=patient_name> </td>
	<td ><input name="Male" id="Male" type="text" class="XBox box1" >&nbsp; &nbsp; &nbsp; &nbsp; M</td>
	<td ><input name="Female" id="Female" type="text" class="XBox box1" >&nbsp; &nbsp;&nbsp; &nbsp;  F</td>
	<td colspan=6 style='border:.75pt solid black;'>&nbsp; <b>DOB:</b><input name="DOB" id="DOB" type="text" class="noborder" style="width:100px; font-family:sans-serif; "  oscarDB=dobc> </td>
   </tr>
   <tr>
	<td colspan=16 style='border:.75pt solid black;'><b>Address:</b><input name="Address" id="Address" type="text"  style="width:650px; font-family:sans-serif;"  oscarDB=addressline></td>
   </tr>
   <tr>
	<td colspan=8 style='border:.75pt solid black;'><b>PHN:</b><input name="PHN" id="PHN" type="text" style=" width:145px; font-family:sans-serif; "  oscarDB=hinc></td>
	<td colspan=8 style='border:.75pt solid black;'><b>Email:</b><input name="Email" id="Email" type="text" style=" width:200px; font-family:sans-serif; "  oscarDB=email></td>
   </tr>
   <tr>
	<td colspan=8 style='border:.75pt solid black;'><b>Home Phone:</b><input name="PhoneHome" id="PhoneHome" type="text" style="width:167px; font-family:sans-serif;"  oscarDB=phone></td>
	<td colspan=8 style='border:.75pt solid black;'><b>Cell Phone:</b><input name="Cel" id="Cel" type="text" style="width:167px; height:17px; font-family:sans-serif;"  oscarDB=cell></td>
   </tr>
   <tr>
	<td colspan=16 style='border:.75pt solid white;'>&nbsp;</td>
   </tr>
   <tr>
	<th colspan=16 style='border:.75pt solid black; background:#D3D3D3;'><b>REASON FOR REFERRAL</b></th>
   </tr>
   <tr>
	<td colspan=16 style='border:.75pt solid white;'>&nbsp;</td>
   </tr>
   <tr style='border:.75pt solid black;'>
	<td ><b>Priority:</b></td>
	<td  colspan=2 ><input name="Urgent" id="Urgent" type="text" class="XBox box1" >&nbsp; &nbsp; &nbsp; &nbsp; Urgent</td>
	<td  colspan=2 ><input name="ER" id="ER" type="text" class="XBox box1" >&nbsp; &nbsp;  &nbsp; &nbsp; ER Hospital</td>
	<td  colspan=2 ><input name="Non-Urgent" id="Non-Urgent" type="text" class="XBox box1" >&nbsp; &nbsp; &nbsp; &nbsp; Non-Urgent </td>
	<td  colspan=2 ><input name="Yearly" id="Yearly" type="text" class="XBox box1" >&nbsp; &nbsp; &nbsp; &nbsp; Yearly FU </td>
	<td colspan=2 ><input name="Specialist" id="Specialist" type="text" class="XBox box1" >&nbsp; &nbsp; &nbsp; &nbsp; Specialist office</td>
	<td  colspan=2 ><input name="BCCA" id="BCCA" type="text" class="XBox box1" >&nbsp; &nbsp; &nbsp; &nbsp; B.C.C.A. </td>
   </tr>
   <tr>
	<td colspan=4 rowspan=6 style="vertical-align: top;"><b>Reason:</b><br>(Please check the box)</td>
	<td colspan=5 style='border:.75pt solid black;'> <input name="Environmental" id="Environmental" type="text" class="XBox box1" >&nbsp; &nbsp; &nbsp; &nbsp; Environmental/Food Allergies</td>
	<td colspan=7 style='border:.75pt solid black;'> <input name="Asthma" id="Asthma" type="text" class="XBox box1" >&nbsp; &nbsp; &nbsp; &nbsp; Asthma/Spirometry</td>
	</tr>
   <tr>
	<td colspan=5 style='border:.75pt solid black;'> <input name="Immunotherapy" id="Immunotherapy" type="text" class="XBox box1" >&nbsp; &nbsp; &nbsp; &nbsp; Immunotherapy</td>
	<td colspan=7 style='border:.75pt solid black;'> <input name="Immunodeficiency" id="Immunodeficiency" type="text" class="XBox box1" >&nbsp; &nbsp; &nbsp; &nbsp; Immunodeficiency</td>
	</tr>
   <tr>
	<td colspan=5 style='border:.75pt solid black;'> <input name="Urticarial" id="Urticarial" type="text" class="XBox box1" >&nbsp; &nbsp; &nbsp; &nbsp; Acute/Chronic Urticarial</td>
	<td colspan=7 style='border:.75pt solid black;'> <input name="LatexAllergy" id="LatexAllergy" type="text" class="XBox box1" >&nbsp; &nbsp; &nbsp; &nbsp; Latex Allergy</td>
	</tr>
   <tr>
	<td colspan=5 style='border:.75pt solid black;'> <input name="Rhinitis" id="Rhinitis" type="text" class="XBox box1" >&nbsp; &nbsp; &nbsp; &nbsp; Chronic Rhinitis/Sinusitis</td>
	<td colspan=7 style='border:.75pt solid black;'> <input name="Drug" id="Drug" type="text" class="XBox box1" >&nbsp; &nbsp; &nbsp; &nbsp; Drug Allergy</td>
	</tr>
   <tr>
	<td colspan=5 style='border:.75pt solid black;'> <input name="Atopic" id="Atopic" type="text" class="XBox box1" >&nbsp; &nbsp; &nbsp; &nbsp; Atopic/Contact Dermatitis</td>
	<td colspan=7 style='border:.75pt solid black;'> <input name="Venom" id="Venom" type="text" class="XBox box1" >&nbsp; &nbsp; &nbsp; &nbsp; Venom Allergy</td>
	</tr>
   <tr>
	<td colspan=5 style='border:.75pt solid black;'> <input name="Angioedema" id="Angioedema" type="text" class="XBox box1" >&nbsp; &nbsp; &nbsp; &nbsp; Angioedema</td>
	<td colspan=7 style='border:.75pt solid black;'> <input name="OtherReason" id="OtherReason" type="text" class="XBox box1" >&nbsp; &nbsp; &nbsp; &nbsp; Other</td>
	</tr>
    <tr>
	<td colspan=4 style='border:.75pt solid black;'>Follow Up</td>
	<td colspan=5 style='border:.75pt solid black;'> <input name="YearlyVisit" id="YearlyVisit" type="text" class="XBox box1" >&nbsp; &nbsp; &nbsp; &nbsp; Yearly Visit</td>
	<td colspan=7 style='border:.75pt solid black;'> <input name="SixMonthVisit" id="SixMonthVisit" type="text" class="XBox box1" >&nbsp; &nbsp; &nbsp; &nbsp; Six Month Visit</td>
	</tr>
   <tr>
	<td colspan=16 style='border:.75pt solid black; '><b>Reason for Consultation:</b></td>
   </tr>
   <tr>
	<td colspan=16 style='border:.75pt solid black; '><textarea name="ReasonForConsult" id="ReasonForConsult" class="noborder" style="width:740px; height:75px;"></textarea></td>
   </tr>
   <tr>
	<td colspan=16 style='border:.75pt solid black; '><b>List of Medications</b></td>
   </tr>
   <tr>
	<td colspan=16 style='border:.75pt solid black; '><textarea name="Medications" id="Medications" class="noborder" style="width:740px; height:50px;" oscarDB=druglist_line></textarea></td>
   </tr>
   <tr>
	<td colspan=16 style='border:.75pt solid black; '><b>Pathology, Radiology and Specialist Consult Reports:</b></td>
   </tr>
   <tr>
	<td colspan=10 style='border:.75pt solid black; '>Please CC Current Pathology, Radiology Report and Attach applicable Consult Reports from Specialists</td>
	<td colspan=6 style='border:.75pt solid black; '>CC: Dr. M Sandhu Billing &#35; 64727</td>
   </tr>
   <tr>
	<td colspan=16 style='border:.75pt solid white;'>&nbsp;</td>
   </tr>
   <tr>
	<td colspan=10 style='border:.75pt solid black; '><b>Referring Physician's Signature: <i>Electronically Signed in EMR</i></b></td>
	<td colspan=6 style='border:.75pt solid black; '><b>Date</b><input name="Date2" id="Date2" type="text"   oscarDB=today ></td>
   </tr>
   <tr>
	<td colspan=10 style='border:.75pt solid black; '><b>Referring Physician's Name: </b><input name="FamilyPhysician" id="FamilyPhysician" type="text" class="noborder" style=" width:246px;"  oscarDB=provider_name_first_init></td>
	<td colspan=6 style='border:.75pt solid black; '><b>MSP Billing &#35;</b><input name="MSP" id="MSP" type="text" style=" width:100px;"  oscarDB=doctor_ohip_no ></td>
   </tr>
   <tr>
	<td colspan=1 rowspan=2 style="vertical-align: top; "><b>Address:</b></td>
	<td colspan=9 rowspan=2 style="vertical-align: top; "><textarea name="ClincAddress" id="ClincAddress" class="noborder" style="width:450px; height:70px;" oscarDB=clinic_address></textarea></td>
	<td colspan=6 style='border:.75pt solid black; '><b>Fax:</b><input name="Fax" id="Fax" type="text"   oscarDB=clinic_fax ></td>
   </tr>
   <tr>
	<td colspan=6 style='border:.75pt solid black; '><b>Phone:</b><input name="ClinicPhone" id="ClinicPhone" type="text" style=" width:100px;"  oscarDB=clinic_phone ></td>
   </tr>
   <tr>
	<td colspan=10 style='border:.75pt solid black; '><b>Please do not send a cover letter</b></td>
	<td colspan=6 style='border:.75pt solid black; '><b>Pages</b></td>
   </tr>
  </table>

<input name="PatientGender" id="PatientGender" type="hidden" oscarDB=sex>



 <div class="DoNotPrint" id="BottomButtons" style="position: absolute; top:1000px; left:0px;">
	 <table><tr><td>
		 Subject: <input name="subject" size="40" type="text"> <br> 
		<input value="Submit" name="SubmitButton" id="SubmitButton" type="submit" onclick=" releaseDirtyFlag();"> 
			<input value="Reset" name="ResetButton" id="ResetButton" type="reset"> 
			<input value="Print" name="PrintButton" id="PrintButton" type="button" onclick="formPrint();"> 
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	 </td></tr></table>
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 </form>

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