Personal tools
Navigation
 

Canadian Diabetes Association Insulin Rx HTML

HTML icon CDAInsulinRx.html — HTML, 29 kB (29923 bytes)

File contents

<html>
<head>

<!------Created March 6, 2014 by Chris Sedergreen--->
<!----- Do not use apostrophes - they do not allow for proper eForm zip inside Oscar.  Instead, use: &#8217; --->
<title>CDAInsulinRX</title>


<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 type='text/javascript' src='$../../../js/jquery-1.7.1.min.js'></script>
<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>

<!-------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 = 1050;
		}
		}
</script>
<!----------End optimize window script---------->

<!-- scripts for Xbox functions -->
<script language="javascript">
$(document).ready(function() {
	  $( '.Xbox' ).click(function() {
		  var bc = $( this ).css( 'background-color' );
		  if (bc=='rgb(0, 0, 0)') {
			  $( this ).css( 'background-color', 'white' );
			  $( this ).val('');
		  } else {
			  $( this ).css( 'background-color', 'rgb(0, 0, 0)' );
			  $( this ).val('X');
		  }
	});

$( '.Xbox' ).keypress(function(event) {
	  // any key press except tab will constitute a value change to the checkbox
	  if (event.which != 0){
		  $( this ).click();
		  return false;
		  }
	});

});
</script>


</head>

<body onload="">
<img id='BGImage' src="${oscar_image_path}CDAInsulinRx1.png" style="position: absolute; left: 0px; top: 0px; width:1000px">
<form method="post" action="" name="FormName" id="FormName" >

<input name="doctor" id="doctor" type="text" class="noborder" style="position:absolute; left:412px; top:17px; width:225px; height:22px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white; text-decoration:underline;"  oscarDB=doctor>
<input name="patient_name" id="patient_name" type="text" class="noborder" style="position:absolute; left:729px; top:17px; width:237px; height:22px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white; text-decoration:underline;"  oscarDB=patient_name>
<input name="clinic_addressLineFull" id="clinic_addressLineFull" type="text" class="noborder" style="position:absolute; left:358px; top:41px; width:278px; height:22px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white; text-decoration:underline;"  oscarDB=clinic_addressLineFull>
<input name="addressline" id="addressline" type="text" class="noborder" style="position:absolute; left:686px; top:41px; width:279px; height:22px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white; text-decoration:underline;"  oscarDB=addressline>
<input name="clinic_phone" id="clinic_phone" type="text" class="noborder" style="position:absolute; left:336px; top:64px; width:138px; height:22px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white; text-decoration:underline;"  oscarDB=clinic_phone>
<input name="clinic_fax" id="clinic_fax" type="text" class="noborder" style="position:absolute; left:502px; top:64px; width:134px; height:22px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white; text-decoration:underline;"  oscarDB=clinic_fax>
<input name="phone" id="phone" type="text" class="noborder" style="position:absolute; left:666px; top:64px; width:100px; height:22px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white; text-decoration:underline;"  oscarDB=phone>
<span style="position:absolute; left:768px; top:66px; font-family:Arial; font-style:normal; font-size:10px;">(Home)</span>

<input name="phone2" id="phone2" type="text" class="noborder" style="position:absolute; left:810px; top:64px; width:100px; height:22px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white; text-decoration:underline;"  oscarDB=cell>
<span style="position:absolute; left:912px; top:66px; font-family:Arial; font-style:normal; font-size:10px;">(Cell)</span>

<input name="AutoName1" id="AutoName1" type="text" class="Xbox" style="position:absolute; left:403px; top:124px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName2" id="AutoName2" type="text" class="Xbox" style="position:absolute; left:416px; top:138px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName3" id="AutoName3" type="text" class="Xbox" style="position:absolute; left:416px; top:151px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName4" id="AutoName4" type="text" class="Xbox" style="position:absolute; left:565px; top:124px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName5" id="AutoName5" type="text" class="Xbox" style="position:absolute; left:578px; top:139px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName6" id="AutoName6" type="text" class="Xbox" style="position:absolute; left:643px; top:138px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName7" id="AutoName7" type="text" class="Xbox" style="position:absolute; left:577px; top:152px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName8" id="AutoName8" type="text" class="Xbox" style="position:absolute; left:243px; top:175px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName9" id="AutoName9" type="text" class="Xbox" style="position:absolute; left:255px; top:189px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName10" id="AutoName10" type="text" class="Xbox" style="position:absolute; left:320px; top:191px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName11" id="AutoName11" type="text" class="Xbox" style="position:absolute; left:255px; top:204px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName12" id="AutoName12" type="text" class="Xbox" style="position:absolute; left:404px; top:176px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName13" id="AutoName13" type="text" class="Xbox" style="position:absolute; left:417px; top:190px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName14" id="AutoName14" type="text" class="Xbox" style="position:absolute; left:416px; top:202px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName15" id="AutoName15" type="text" class="noborder" style="position:absolute; left:726px; top:141px; width:63px; height:19px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:white; text-decoration:underline;" value="">
<input name="AutoName16" id="AutoName16" type="text" class="noborder" style="position:absolute; left:814px; top:167px; width:46px; height:19px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:white; text-decoration:underline;" value="">
<input name="TargetBSL1" id="TargetBSL1" type="text" class="noborder" style="position:absolute; left:826px; top:199px; width:46px; height:19px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:white; text-decoration:underline;" value="">
<input name="AutoName17" id="AutoName17" type="text" class="Xbox" style="position:absolute; left:243px; top:227px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName18" id="AutoName18" type="text" class="Xbox" style="position:absolute; left:255px; top:240px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName19" id="AutoName19" type="text" class="Xbox" style="position:absolute; left:321px; top:240px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName20" id="AutoName20" type="text" class="Xbox" style="position:absolute; left:256px; top:254px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName21" id="AutoName21" type="text" class="Xbox" style="position:absolute; left:404px; top:226px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName22" id="AutoName22" type="text" class="Xbox" style="position:absolute; left:416px; top:240px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName23" id="AutoName23" type="text" class="Xbox" style="position:absolute; left:482px; top:241px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName24" id="AutoName24" type="text" class="Xbox" style="position:absolute; left:416px; top:256px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName25" id="AutoName25" type="text" class="Xbox" style="position:absolute; left:564px; top:226px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName26" id="AutoName26" type="text" class="Xbox" style="position:absolute; left:577px; top:241px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName27" id="AutoName27" type="text" class="Xbox" style="position:absolute; left:642px; top:240px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName28" id="AutoName28" type="text" class="Xbox" style="position:absolute; left:577px; top:255px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName29" id="AutoName29" type="text" class="noborder" style="position:absolute; left:725px; top:242px; width:65px; height:18px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:white; text-decoration:underline;" value="">
<input name="AutoName30" id="AutoName30" type="text" class="noborder" style="position:absolute; left:725px; top:260px; width:65px; height:18px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:white; text-decoration:underline;" value="">
<input name="AutoName31" id="AutoName31" type="text" class="noborder" style="position:absolute; left:725px; top:278px; width:65px; height:18px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:white; text-decoration:underline;" value="">
<input name="AutoName32" id="AutoName32" type="text" class="Xbox" style="position:absolute; left:243px; top:278px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName33" id="AutoName33" type="text" class="Xbox" style="position:absolute; left:255px; top:291px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName34" id="AutoName34" type="text" class="Xbox" style="position:absolute; left:255px; top:306px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName35" id="AutoName35" type="text" class="Xbox" style="position:absolute; left:404px; top:277px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName36" id="AutoName36" type="text" class="Xbox" style="position:absolute; left:417px; top:291px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName37" id="AutoName37" type="text" class="Xbox" style="position:absolute; left:416px; top:306px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName38" id="AutoName38" type="text" class="Xbox" style="position:absolute; left:243px; top:329px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName39" id="AutoName39" type="text" class="Xbox" style="position:absolute; left:255px; top:343px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName40" id="AutoName40" type="text" class="Xbox" style="position:absolute; left:255px; top:357px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName41" id="AutoName41" type="text" class="Xbox" style="position:absolute; left:243px; top:376px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName42" id="AutoName42" type="text" class="Xbox" style="position:absolute; left:255px; top:390px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName43" id="AutoName43" type="text" class="Xbox" style="position:absolute; left:255px; top:404px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName44" id="AutoName44" type="text" class="Xbox" style="position:absolute; left:404px; top:329px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName45" id="AutoName45" type="text" class="Xbox" style="position:absolute; left:416px; top:343px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="acBrekky2" id="acBrekky2" type="text" class="noborder" style="position:absolute; left:725px; top:344px; width:60px; height:18px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:white; text-decoration:underline;" value="">
<input name="acSupper2" id="acSupper2" type="text" class="noborder" style="position:absolute; left:725px; top:362px; width:60px; height:18px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:white; text-decoration:underline;" value="">
<input name="BrekkyDoseInc" id="BrekkyDoseInc" type="text" class="noborder" style="position:absolute; left:859px; top:385px; width:44px; height:18px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:white; text-decoration:underline;" value="">
<input name="PreSupperTarget" id="PreSupperTarget" type="text" class="noborder" style="position:absolute; left:835px; top:419px; width:44px; height:15px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:white; text-decoration:underline;" value="">
<input name="PreSupperInc" id="PreSupperInc" type="text" class="noborder" style="position:absolute; left:862px; top:435px; width:44px; height:15px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:white; text-decoration:underline;" value="">
<input name="FBSTarget" id="FBSTarget" type="text" class="noborder" style="position:absolute; left:795px; top:463px; width:44px; height:18px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:white; text-decoration:underline;" value="">
<input name="AutoName46" id="AutoName46" type="text" class="Xbox" style="position:absolute; left:243px; top:422px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName47" id="AutoName47" type="text" class="Xbox" style="position:absolute; left:256px; top:437px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName48" id="AutoName48" type="text" class="Xbox" style="position:absolute; left:255px; top:449px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName49" id="AutoName49" type="text" class="Xbox" style="position:absolute; left:404px; top:422px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName50" id="AutoName50" type="text" class="Xbox" style="position:absolute; left:417px; top:436px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName51" id="AutoName51" type="text" class="Xbox" style="position:absolute; left:481px; top:437px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName52" id="AutoName52" type="text" class="Xbox" style="position:absolute; left:403px; top:455px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName53" id="AutoName53" type="text" class="Xbox" style="position:absolute; left:417px; top:469px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName54" id="AutoName54" type="text" class="Xbox" style="position:absolute; left:403px; top:490px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName55" id="AutoName55" type="text" class="Xbox" style="position:absolute; left:416px; top:504px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName56" id="AutoName56" type="text" class="Xbox" style="position:absolute; left:243px; top:534px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName57" id="AutoName57" type="text" class="Xbox" style="position:absolute; left:243px; top:547px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName58" id="AutoName58" type="text" class="Xbox" style="position:absolute; left:243px; top:560px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName59" id="AutoName59" type="text" class="Xbox" style="position:absolute; left:404px; top:534px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName60" id="AutoName60" type="text" class="Xbox" style="position:absolute; left:403px; top:548px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName61" id="AutoName61" type="text" class="Xbox" style="position:absolute; left:564px; top:533px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName62" id="AutoName62" type="text" class="Xbox" style="position:absolute; left:243px; top:587px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName63" id="AutoName63" type="text" class="Xbox" style="position:absolute; left:242px; top:601px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName64" id="AutoName64" type="text" class="Xbox" style="position:absolute; left:387px; top:600px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName65" id="AutoName65" type="text" class="Xbox" style="position:absolute; left:504px; top:600px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName66" id="AutoName66" type="text" class="Xbox" style="position:absolute; left:619px; top:587px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName67" id="AutoName67" type="text" class="Xbox" style="position:absolute; left:666px; top:586px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName68" id="AutoName68" type="text" class="Xbox" style="position:absolute; left:713px; top:586px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName69" id="AutoName69" type="text" class="Xbox" style="position:absolute; left:762px; top:586px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName70" id="AutoName70" type="text" class="Xbox" style="position:absolute; left:834px; top:586px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:9px; text-align:center; background-color:white;" value="">
<input name="AutoName71" id="AutoName71" type="text" class="noborder" style="position:absolute; left:329px; top:623px; width:52px; height:18px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:white; text-decoration:underline;" value="">
<input name="AutoName72" id="AutoName72" type="text" class="noborder" style="position:absolute; left:470px; top:623px; width:52px; height:18px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:white; text-decoration:underline;" value="">
<input name="AutoName73" id="AutoName73" type="text" class="noborder" style="position:absolute; left:649px; top:623px; width:52px; height:18px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:white; text-decoration:underline;" value="">
<input name="AutoName74" id="AutoName74" type="text" class="noborder" style="position:absolute; left:793px; top:623px; width:52px; height:18px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:center; background-color:white; text-decoration:underline;" value="">
<input name="today" id="today" type="text" class="noborder" style="position:absolute; left:383px; top:655px; width:142px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white; text-decoration:underline;"  oscarDB=today>
<input name="doctor_cpsid" id="doctor_cpsid" type="text" class="noborder" style="position:absolute; left:403px; top:681px; width:122px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white; text-decoration:underline;"  oscarDB=doctor_cpsid>
<input name="doctor2" id="doctor2" type="text" class="noborder" style="position:absolute; left:98px; top:681px; width:246px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white; text-decoration:underline;"  oscarDB=doctor>


 <div class="DoNotPrint" id="BottomButtons" style="position: absolute; top:800px; left:0px;">
	 <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 & Submit" name="PrintSubmitButton" id="PrintSubmitButton" type="button" onclick="formPrint();releaseDirtyFlag();setTimeout('SubmitButton.click()',1000);"> 
	 </td></tr></table>
 </div>
 </form>

</body>
</html>

Document Actions

 

Download button

DOWNLOAD OSCAR FOR TESTING

 

eForms button

DOWNLOAD SHARED E-FORMS


 Customize button

FIND PLUG-INS AND TWEAKS
FOR YOUR OSCAR EMR

 

Subscribe Button

SUBSCRIBE TO DISCUSSION LIST 
(SEE ALL LISTS)

  

Help button

ACCESS THE ONLINE MANUALS
(PAID SUPPORT)