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VIHA Kidney Clinic Referral

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HTML icon viha referral to kidney clinic.html — HTML, 7 kB (7853 bytes)

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<html>

<head>

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




<!-- scripts to confirm closing of window if it hadn't 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 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>


</head>

<body>
<img id='BGImage' style="position: absolute; left: 12; top: 16; width:750px; height:971px; "IMG SRC="${oscar_image_path}viha referral to kidney clinic.png"></div>
<!---->


<form method="POST" action="">
<!-- ----------------------------All textfields/checkboxes/textareas go here...------ -->

	<input type="text" class="noborder" name="lastname" style="width: 170px; font-family: Arial; font-size: 12px; position: absolute; left:93px; top:210px;" oscarDB=patient_nameL>

	<input type="text" class="noborder" name="firstname" style="width: 168px; font-family: Arial; font-size: 12px; position: absolute; left:339px; top:210px;" oscarDB=patient_nameF>

	<input type="text" class="noborder" name="DOB" style="width: 204px; font-family: Arial; font-size: 12px; position: absolute; left:547px; top:210px;" oscarDB=DOB>
 
	<input type="text" class="noborder" name="PHN" style="width: 154px; font-family: Arial; font-size: 12px; position: absolute; left:56px; top:244px;" oscarDB=HINc>

	<input type="text" class="noborder" name="patienthomephone" style="width: 115px; font-family: Arial; font-size: 12px;position: absolute; left:317px; top:244px;" oscarDB=phone>

	<input type="text" class="noborder" name="patientworkphone" style="width: 135px; font-family: Arial; font-size: 12px;position: absolute; left:449px; top:244px;" oscarDB=phone2>

	<input type="text" class="noborder" name="faxnumberpatient" style="width: 135px; font-family: Arial; font-size: 12px; position: absolute; left:612px; top:244px;" >

  <input type="text" class="noborder" name="addresspatient" style="width: 671px; font-family: Arial; font-size: 12px; position: absolute; left:79px; top:279px;" oscarDB=addressLine>

  <input type="text" class="noborder" name="emailaddress" style="width: 147px; font-family: Arial; font-size: 12px;position: absolute; left:115px; top:314px;">

	<input type="text" class="noborder" name="contactpersonifnotpatient" style="width: 311px; font-family: Arial; font-size: 12px; position: absolute; left:439px; top:314px;" >
  
	<input type="text" class="noborder" name="nephrologist" style="width: 273px; font-family: Arial; font-size: 12px; position: absolute; left:111px; top:348px;"  >
  
	<input type="text" class="noborder" name="GP" style="width: 335px; font-family: Arial; font-size: 12px; position: absolute; left:415px; top:348px;" oscarDB=doctor  >
  
	<input type="text" class="noborder" name="referringphysician" style="width: 275px; font-family: Arial; font-size: 14px; position: absolute; left:144px; top:383px; width: 275px;"  oscarDB=current_user>
</div>

<div style=""> 
	<input type="text" class="noborder" name="referringphysician" style="width: 55px; font-family: Arial; font-size: 14px; position: absolute; left:426px; top:383px; width: 55px;"  oscarDB=current_user_ohip_no>
</div>

<div style=""> 
	<input type="text" class="noborder" name="nephrologydr" style="width: 186px; font-family: Arial; font-size: 12px; position: absolute; left:557px; top:415px;"  >
  
	<input type="text" class="noborder" name="ifnodr" style="width: 227px; font-family: Arial; font-size: 12px; position: absolute; left:516px; top:449px;" >
  
	<input type="text" class="noborder" name="causeofkidneydisease" style="width: 170px; font-family: Arial; font-size: 12px; position: absolute; left:214px; top:481px;"  >
  
  <input type="text" class="noborder" name="secondarydiagnosis" style="width: 196px; font-family: Arial; font-size: 12px; position: absolute; left:188px; top:514px;"  >
  
  <input type="text" class="noborder" name="weight" style="width: 302px; font-family: Arial; font-size: 12px; position: absolute; left:83px; top:546px;"  >
  
	<input type="text" class="noborder" name="GFR" style="width: 92px; font-family: Arial; font-size: 12px; position: absolute; left:64px; top:584px;"  >
  
  <input type="text" class="noborder" name="serumcreatinine" style="width: 90px; font-family: Arial; font-size: 12px; position: absolute; left:294px; top:579px;"  >
  
  <input type="text" class="noborder" name="languagebarrier" style="width: 73px; font-family: Arial; font-size: 12px; position: absolute; left:673px; top:515px;"  >
  
	<input type="text" class="noborder" name="sensorydeficit" style="width: 87px; font-family: Arial; font-size: 12px; position: absolute; left:659px; top:547px;"  >
  
	<input type="text" class="noborder" name="other" style="width: 153px; font-family: Arial; font-size: 12px; position: absolute; left:589px; top:581px;"  >
  
	<input type="text" class="noborder" name="MDS" style="width: 160px; font-family: Arial; font-size: 12px; position: absolute; left:70px; top:684px;"  >
  
	<input type="text" class="noborder" name="VIHA" style="width: 158px; font-family: Arial; font-size: 12px; position: absolute; left:274px; top:684px;"  >
  
  <input type="text" class="noborder" name="otherlab" style="width: 269px; font-family: Arial; font-size: 12px; position: absolute; left:480px; top:684px;"  >
 
  <input type="checkbox" name="nonephrology" style="position: absolute; left:459px; top:414px;">
 
  <input type="checkbox" name="yesnephrology" style="position: absolute; left:501px; top:414px;">
 
  <input type="checkbox" name="senttonephrologyno" style="position: absolute; left:390px; top:448px;">
 
  <input type="checkbox" name="senttonephrologyyes" style="position: absolute; left:441px; top:448px;">

  <input type="checkbox" name="coping" style="position: absolute; left:394px; top:546px;">
 
  <input type="checkbox" name="urgent" style="position: absolute; left:394px; top:579px;">
 
  <input type="checkbox" name="diet" style="position: absolute; left:394px; top:512px;">
  

   <div class="DoNotPrint" id="BottomButtons" style="position: absolute; top:967px; left:73px;"> 
    <table><tr><td>
		 Subject: <input name="subject" size="40" type="text"> 
			<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();"> 
			<input value="Print and Submit" name="PrintSubmitButton" id="PrintSubmitButton" type="button" onClick="formPrint();releaseDirtyFlag();setTimeout('SubmitButton.click()',1000);"> 
	 </td></tr></table>
 </div>
</form>
</body>

</html>

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