Coast Mountain Bus Short Term Disability eForm HTML
CoastMountainBus.HTML
—
HTML,
31 kB (32346 bytes)
File contents
<HTML>
<head>
<link rel="stylesheet" type="text/css" media="print" href="${oscar_image_path}JSMPC.css" />
<title>Master eform</title>
<style type="text/css" media="print">
.DoNotPrint {
display: none;
}
.noborder {
border : 0px;
background: transparent;
scrollbar-3dlight-color: transparent;
scrollbar-3dlight-color: transparent;
scrollbar-arrow-color: transparent;
scrollbar-base-color: transparent;
scrollbar-darkshadow-color: transparent;
scrollbar-face-color: transparent;
scrollbar-highlight-color: transparent;
scrollbar-shadow-color: transparent;
scrollbar-track-color: transparent;
background: transparent;
overflow: hidden;
}
</style>
<script language="javascript" type="text/javascript">
/****************************
startup functions
****************************/
function startUp()
{
// shows the forms on development machine from notepad ++ - saves you from uploading to the server to input alignments
var strLoc = window.location.href.toLowerCase();
if(strLoc.indexOf("https") == -1)
{
//page1
var src = document.getElementById('BGImage').src;
document.getElementById('BGImage').src = src.replace('$%7Boscar_image_path%7D','');
}
setDocumentTitle('Master eform',document.getElementById('PatientName').value);
setDefaults();
}
function setDocumentTitle(Title,PatientName)
{
// set document title
document.title = Title + ' - ' + PatientName;
}
/****************************
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 = 1120; -->
top.window.outerWidth = 1400;
}
}
</script>
<!----------End optimize window 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 = false;
}
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 type="text/javascript" language="javascript">
function checkGender(){
if (document.getElementById('PatientGender').value == 'M'){
document.getElementById('Male').checked = true;
}else if (document.getElementById('PatientGender').value == 'F'){
document.getElementById('Female').checked = true;
}
}
</script>
</head>
<body>
<form method="post" action="" name="twoPageForm">
<!-- PAGE 1 ----------------------------------------------------------------------------------------------- -->
<div id="page1" style="page-break-after:always;position:relative;" >
<img src="${oscar_image_path}CMB1.png" style="position: relative; left: 0px; top: 0px; width:750px">
<input name="first_last_name" id="first_last_name" type="text" class="noborder" style="position:absolute; left:193px; top:100px; width:213px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:8px; text-align:left; background-color:white;" oscarDB=first_last_name>
<input name="dobc2" id="dobc2" type="text" class="noborder" style="position:absolute; left:507px; top:100px; width:129px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:8px; text-align:center; background-color:white;" oscarDB=dobc2>
<input name="EmployeeNumber" id="EmployeeNumber" type="text" class="noborder" style="position:absolute; left:208px; top:121px; width:198px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:8px; text-align:center; background-color:white;" value="">
<input name="SeniorityNumber" id="SeniorityNumber" type="text" class="noborder" style="position:absolute; left:508px; top:128px; width:129px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:8px; text-align:center; background-color:transparent;" value="">
<input name="Height" id="Height" type="text" class="noborder" style="position:absolute; left:201px; top:143px; width:83px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:8px; text-align:center; background-color:white;" oscarDB=m$HT#value>
<input name="Weight" id="Weight" type="text" class="noborder" style="position:absolute; left:361px; top:142px; width:55px; height:22px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:8px; text-align:center; background-color:white;" oscarDB=m$WT#value>
<input name="PrimaryDx" id="PrimaryDx" type="text" class="noborder" style="position:absolute; left:186px; top:173px; width:451px; height:22px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:8px; text-align:left; background-color:transparent;" value="">
<input name="SecondaryDx" id="SecondaryDx" type="text" class="noborder" style="position:absolute; left:194px; top:195px; width:442px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:8px; text-align:left; background-color:white;" value="">
<input name="Symptoms" id="Symptoms" type="text" class="noborder" style="position:absolute; left:240px; top:215px; width:398px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:8px; text-align:left; background-color:transparent;" value="">
<textarea name="Findings" id="Findings" class="noborder" style="position:absolute; left:143px; top:252px; width:500px; height:52px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:8px; text-align:left; background-color:white;" ></textarea>
<input name="AdmitDate" id="AdmitDate" type="text" class="noborder" style="position:absolute; left:278px; top:312px; width:109px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:7px; text-align:center; background-color:white;" value="">
<input name="DischargeDate" id="DischargeDate" type="text" class="noborder" style="position:absolute; left:494px; top:312px; width:112px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:7px; text-align:center; background-color:white;" value="">
<input name="OPDate" id="OPDate" type="text" class="noborder" style="position:absolute; left:280px; top:336px; width:107px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:7px; text-align:center; background-color:transparent;" value="">
<input name="HospitalName" id="HospitalName" type="text" class="noborder" style="position:absolute; left:226px; top:357px; width:385px; height:17px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:7px; text-align:center; background-color:white;" value="">
<input name="BedPatientFrom" id="BedPatientFrom" type="text" class="noborder" style="position:absolute; left:198px; top:387px; width:104px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:7px; text-align:center; background-color:transparent;" value="">
<input name="BedPatientTo" id="BedPatientTo" type="text" class="noborder" style="position:absolute; left:386px; top:386px; width:101px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:7px; text-align:center; background-color:white;" value="">
<input name="DaySurgeryDate" id="DaySurgeryDate" type="text" class="noborder" style="position:absolute; left:383px; top:412px; width:105px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:7px; text-align:center; background-color:white;" value="">
<input name="DyalysisFrom" id="DyalysisFrom" type="text" class="noborder" style="position:absolute; left:200px; top:453px; width:100px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:7px; text-align:center; background-color:transparent;" value="">
<input name="DyalysisTo" id="DyalysisTo" type="text" class="noborder" style="position:absolute; left:382px; top:453px; width:105px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:8px; text-align:center; background-color:white;" value="">
<input name="ChemoFrom" id="ChemoFrom" type="text" class="noborder" style="position:absolute; left:199px; top:496px; width:101px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:7px; text-align:center; background-color:transparent;" value="">
<input name="ChemoTo" id="ChemoTo" type="text" class="noborder" style="position:absolute; left:386px; top:493px; width:102px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:7px; text-align:center; background-color:white;" value="">
<input name="RadiationFrom" id="RadiationFrom" type="text" class="noborder" style="position:absolute; left:199px; top:538px; width:99px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:7px; text-align:center; background-color:transparent;" value="">
<input name="RadiationTo" id="RadiationTo" type="text" class="noborder" style="position:absolute; left:384px; top:537px; width:103px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:7px; text-align:center; background-color:transparent;" value="">
<input name="ERDate" id="ERDate" type="text" class="noborder" style="position:absolute; left:384px; top:584px; width:102px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:7px; text-align:center; background-color:transparent;" value="">
<input name="SurgicalProcedure" id="SurgicalProcedure" type="text" class="noborder" style="position:absolute; left:284px; top:624px; width:343px; height:22px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:7px; text-align:center; background-color:white;" value="">
<input name="SurgeryDate" id="SurgeryDate" type="text" class="noborder" style="position:absolute; left:221px; top:649px; width:106px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:7px; text-align:center; background-color:white;" value="">
<input name="Surgeon" id="Surgeon" type="text" class="noborder" style="position:absolute; left:445px; top:649px; width:180px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:7px; text-align:center; background-color:transparent;" value="">
<input name="OnsetDate" id="OnsetDate" type="text" class="noborder" style="position:absolute; left:372px; top:672px; width:100px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:7px; text-align:center; background-color:transparent;" value="">
<input name="SameBeforeYes" id="SameBeforeYes" type="checkbox" style="position:absolute; left:396px; top:696px; ">
<input name="SameBeforeNo" id="SameBeforeNo" type="checkbox" style="position:absolute; left:435px; top:697px; ">
<textarea name="SimialrDetails" id="SimialrDetails" class="noborder" style="position:absolute; left:180px; top:729px; width:469px; height:30px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:7px; text-align:left; background-color:white;" ></textarea>
<textarea name="Treatment" id="Treatment" class="noborder" style="position:absolute; left:143px; top:775px; width:509px; height:35px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:7px; text-align:left; background-color:white;" ></textarea>
<input name="Month1" id="Month1" type="text" class="noborder" style="position:absolute; left:144px; top:834px; width:47px; height:14px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:5px; text-align:left; background-color:white;" value="">
<input name="Year1" id="Year1" type="text" class="noborder" style="position:absolute; left:191px; top:834px; width:20px; height:14px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:5px; text-align:left; background-color:white;" value="">
<input name="Month2" id="Month2" type="text" class="noborder" style="position:absolute; left:144px; top:850px; width:47px; height:14px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:5px; text-align:left; background-color:white;" value="">
<input name="Year2" id="Year2" type="text" class="noborder" style="position:absolute; left:192px; top:850px; width:20px; height:14px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:5px; text-align:left; background-color:white;" value="">
<input name="Month3" id="Month3" type="text" class="noborder" style="position:absolute; left:144px; top:867px; width:47px; height:14px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:5px; text-align:left; background-color:white;" value="">
<input name="Year3" id="Year3" type="text" class="noborder" style="position:absolute; left:192px; top:867px; width:20px; height:14px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:5px; text-align:left; background-color:white;" value="">
<input name="AutoName1" id="AutoName1" type="checkbox" style="position:absolute; left:210px; top:835px; ">
<input name="AutoName2" id="AutoName2" type="checkbox" style="position:absolute; left:224px; top:835px; ">
<input name="AutoName3" id="AutoName3" type="checkbox" style="position:absolute; left:238px; top:835px; ">
<input name="AutoName4" id="AutoName4" type="checkbox" style="position:absolute; left:252px; top:835px; ">
<input name="AutoName5" id="AutoName5" type="checkbox" style="position:absolute; left:266px; top:835px; ">
<input name="AutoName6" id="AutoName6" type="checkbox" style="position:absolute; left:280px; top:835px; ">
<input name="AutoName7" id="AutoName7" type="checkbox" style="position:absolute; left:294px; top:835px; ">
<input name="AutoName8" id="AutoName8" type="checkbox" style="position:absolute; left:308px; top:835px; ">
<input name="AutoName9" id="AutoName9" type="checkbox" style="position:absolute; left:322px; top:835px; ">
<input name="AutoName10" id="AutoName10" type="checkbox" style="position:absolute; left:336px; top:835px; ">
<input name="AutoName11" id="AutoName11" type="checkbox" style="position:absolute; left:350px; top:835px; ">
<input name="AutoName12" id="AutoName12" type="checkbox" style="position:absolute; left:364px; top:835px; ">
<input name="AutoName13" id="AutoName13" type="checkbox" style="position:absolute; left:378px; top:835px; ">
<input name="AutoName14" id="AutoName14" type="checkbox" style="position:absolute; left:392px; top:834px; ">
<input name="AutoName15" id="AutoName15" type="checkbox" style="position:absolute; left:406px; top:835px; ">
<input name="AutoName16" id="AutoName16" type="checkbox" style="position:absolute; left:420px; top:835px; ">
<input name="AutoName17" id="AutoName17" type="checkbox" style="position:absolute; left:434px; top:835px; ">
<input name="AutoName18" id="AutoName18" type="checkbox" style="position:absolute; left:448px; top:835px; ">
<input name="AutoName19" id="AutoName19" type="checkbox" style="position:absolute; left:462px; top:835px; ">
<input name="AutoName20" id="AutoName20" type="checkbox" style="position:absolute; left:476px; top:835px; ">
<input name="AutoName21" id="AutoName21" type="checkbox" style="position:absolute; left:490px; top:835px; ">
<input name="AutoName22" id="AutoName22" type="checkbox" style="position:absolute; left:504px; top:835px; ">
<input name="AutoName23" id="AutoName23" type="checkbox" style="position:absolute; left:518px; top:835px; ">
<input name="AutoName24" id="AutoName24" type="checkbox" style="position:absolute; left:532px; top:835px; ">
<input name="AutoName25" id="AutoName25" type="checkbox" style="position:absolute; left:546px; top:835px; ">
<input name="AutoName26" id="AutoName26" type="checkbox" style="position:absolute; left:560px; top:835px; ">
<input name="AutoName27" id="AutoName27" type="checkbox" style="position:absolute; left:574px; top:835px; ">
<input name="AutoName28" id="AutoName28" type="checkbox" style="position:absolute; left:588px; top:835px; ">
<input name="AutoName29" id="AutoName29" type="checkbox" style="position:absolute; left:602px; top:835px; ">
<input name="AutoName30" id="AutoName30" type="checkbox" style="position:absolute; left:616px; top:835px; ">
<input name="AutoName31" id="AutoName31" type="checkbox" style="position:absolute; left:632px; top:835px;">
<input name="AutoName32" id="AutoName32" type="checkbox" style="position:absolute; left:210px; top:849px; ">
<input name="AutoName33" id="AutoName33" type="checkbox" style="position:absolute; left:224px; top:849px; ">
<input name="AutoName34" id="AutoName34" type="checkbox" style="position:absolute; left:238px; top:849px; ">
<input name="AutoName35" id="AutoName35" type="checkbox" style="position:absolute; left:252px; top:849px; ">
<input name="AutoName36" id="AutoName36" type="checkbox" style="position:absolute; left:266px; top:849px; ">
<input name="AutoName37" id="AutoName37" type="checkbox" style="position:absolute; left:280px; top:849px; ">
<input name="AutoName38" id="AutoName38" type="checkbox" style="position:absolute; left:294px; top:849px; ">
<input name="AutoName39" id="AutoName39" type="checkbox" style="position:absolute; left:308px; top:849px; ">
<input name="AutoName40" id="AutoName40" type="checkbox" style="position:absolute; left:322px; top:849px; ">
<input name="AutoName41" id="AutoName41" type="checkbox" style="position:absolute; left:336px; top:849px; ">
<input name="AutoName42" id="AutoName42" type="checkbox" style="position:absolute; left:350px; top:849px; ">
<input name="AutoName43" id="AutoName43" type="checkbox" style="position:absolute; left:364px; top:848px; ">
<input name="AutoName44" id="AutoName44" type="checkbox" style="position:absolute; left:378px; top:848px; ">
<input name="AutoName45" id="AutoName45" type="checkbox" style="position:absolute; left:392px; top:848px; ">
<input name="AutoName47" id="AutoName47" type="checkbox" style="position:absolute; left:406px; top:848px; ">
<input name="AutoName48" id="AutoName48" type="checkbox" style="position:absolute; left:420px; top:849px; ">
<input name="AutoName49" id="AutoName49" type="checkbox" style="position:absolute; left:436px; top:849px; ">
<input name="AutoName50" id="AutoName50" type="checkbox" style="position:absolute; left:448px; top:849px; ">
<input name="AutoName51" id="AutoName51" type="checkbox" style="position:absolute; left:462px; top:849px; ">
<input name="AutoName52" id="AutoName52" type="checkbox" style="position:absolute; left:476px; top:849px; ">
<input name="AutoName53" id="AutoName53" type="checkbox" style="position:absolute; left:490px; top:849px; ">
<input name="AutoName54" id="AutoName54" type="checkbox" style="position:absolute; left:504px; top:849px; ">
<input name="AutoName55" id="AutoName55" type="checkbox" style="position:absolute; left:518px; top:849px; ">
<input name="AutoName56" id="AutoName56" type="checkbox" style="position:absolute; left:532px; top:849px; ">
<input name="AutoName57" id="AutoName57" type="checkbox" style="position:absolute; left:546px; top:849px; ">
<input name="AutoName58" id="AutoName58" type="checkbox" style="position:absolute; left:560px; top:849px; ">
<input name="AutoName59" id="AutoName59" type="checkbox" style="position:absolute; left:574px; top:849px; ">
<input name="AutoName60" id="AutoName60" type="checkbox" style="position:absolute; left:588px; top:849px; ">
<input name="AutoName61" id="AutoName61" type="checkbox" style="position:absolute; left:602px; top:849px; ">
<input name="AutoName62" id="AutoName62" type="checkbox" style="position:absolute; left:616px; top:849px; ">
<input name="AutoName63" id="AutoName63" type="checkbox" style="position:absolute; left:630px; top:849px; ">
<input name="AutoName64" id="AutoName64" type="checkbox" style="position:absolute; left:210px; top:862px; ">
<input name="AutoName65" id="AutoName65" type="checkbox" style="position:absolute; left:224px; top:861px; ">
<input name="AutoName66" id="AutoName66" type="checkbox" style="position:absolute; left:238px; top:862px; ">
<input name="AutoName67" id="AutoName67" type="checkbox" style="position:absolute; left:252px; top:862px; ">
<input name="AutoName68" id="AutoName68" type="checkbox" style="position:absolute; left:266px; top:861px; ">
<input name="AutoName69" id="AutoName69" type="checkbox" style="position:absolute; left:280px; top:862px; ">
<input name="AutoName70" id="AutoName70" type="checkbox" style="position:absolute; left:294px; top:862px; ">
<input name="AutoName71" id="AutoName71" type="checkbox" style="position:absolute; left:308px; top:862px; ">
<input name="AutoName72" id="AutoName72" type="checkbox" style="position:absolute; left:322px; top:862px; ">
<input name="AutoName73" id="AutoName73" type="checkbox" style="position:absolute; left:336px; top:862px; ">
<input name="AutoName74" id="AutoName74" type="checkbox" style="position:absolute; left:350px; top:862px; ">
<input name="AutoName75" id="AutoName75" type="checkbox" style="position:absolute; left:364px; top:862px; ">
<input name="AutoName76" id="AutoName76" type="checkbox" style="position:absolute; left:378px; top:862px; ">
<input name="AutoName77" id="AutoName77" type="checkbox" style="position:absolute; left:392px; top:862px; ">
<input name="AutoName78" id="AutoName78" type="checkbox" style="position:absolute; left:406px; top:862px; ">
<input name="AutoName79" id="AutoName79" type="checkbox" style="position:absolute; left:420px; top:862px; ">
<input name="AutoName80" id="AutoName80" type="checkbox" style="position:absolute; left:434px; top:862px; ">
<input name="AutoName81" id="AutoName81" type="checkbox" style="position:absolute; left:448px; top:862px; ">
<input name="AutoName82" id="AutoName82" type="checkbox" style="position:absolute; left:462px; top:862px; ">
<input name="AutoName83" id="AutoName83" type="checkbox" style="position:absolute; left:476px; top:862px; ">
<input name="AutoName84" id="AutoName84" type="checkbox" style="position:absolute; left:490px; top:862px; ">
<input name="AutoName85" id="AutoName85" type="checkbox" style="position:absolute; left:504px; top:862px; ">
<input name="AutoName86" id="AutoName86" type="checkbox" style="position:absolute; left:518px; top:862px; ">
<input name="AutoName87" id="AutoName87" type="checkbox" style="position:absolute; left:532px; top:862px; ">
<input name="AutoName88" id="AutoName88" type="checkbox" style="position:absolute; left:546px; top:862px; ">
<input name="AutoName89" id="AutoName89" type="checkbox" style="position:absolute; left:560px; top:862px; ">
<input name="AutoName90" id="AutoName90" type="checkbox" style="position:absolute; left:574px; top:862px; ">
<input name="AutoName91" id="AutoName91" type="checkbox" style="position:absolute; left:588px; top:862px; ">
<input name="AutoName92" id="AutoName92" type="checkbox" style="position:absolute; left:602px; top:862px; ">
<input name="AutoName93" id="AutoName93" type="checkbox" style="position:absolute; left:616px; top:862px; ">
<input name="AutoName94" id="AutoName94" type="checkbox" style="position:absolute; left:630px; top:862px; ">
</div>
<!-- PAGE 2 ----------------------------------------------------------------------------------------------- -->
<div id="page2" style="page-break-after:always;position:relative;" >
<img src="${oscar_image_path}CMB2.png" width="750">
<input name="EDD" id="EDD" type="text" class="noborder" style="position:absolute; left:492px; top:34px; width:99px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:5px; text-align:center; background-color:white;" value="">
<input name="StopWorkDate" id="StopWorkDate" type="text" class="noborder" style="position:absolute; left:492px; top:49px; width:99px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:5px; text-align:center; background-color:white;" value="">
<input name="WorkCausedYes" id="WorkCausedYes" type="checkbox" style="position:absolute; left:515px; top:72px; ">
<input name="WorkCausedNo" id="WorkCausedNo" type="checkbox" style="position:absolute; left:555px; top:72px; ">
<input name="WCBClaimY" id="WCBClaimY" type="checkbox" style="position:absolute; left:134px; top:101px; ">
<input name="WCBClaimN" id="WCBClaimN" type="checkbox" style="position:absolute; left:174px; top:101px; ">
<textarea name="SignificantImpairments" id="SignificantImpairments" class="noborder" style="position:absolute; left:109px; top:128px; width:532px; height:63px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:6px; text-align:left; background-color:transparent;" ></textarea>
<input name="OwnOccupationDate" id="OwnOccupationDate" type="text" class="noborder" style="position:absolute; left:523px; top:192px; width:102px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:6px; text-align:center; background-color:white;" value="">
<input name="ModifiedDutiesDate" id="ModifiedDutiesDate" type="text" class="noborder" style="position:absolute; left:523px; top:215px; width:102px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:6px; text-align:center; background-color:white;" value="">
<input name="AlternateDutiesDate" id="AlternateDutiesDate" type="text" class="noborder" style="position:absolute; left:523px; top:240px; width:102px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:6px; text-align:center; background-color:white;" value="">
<input name="Restrictions" id="Restrictions" type="text" class="noborder" style="position:absolute; left:113px; top:279px; width:533px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:6px; text-align:left; background-color:transparent;" value="">
<textarea name="OtherDocs" id="OtherDocs" class="noborder" style="position:absolute; left:113px; top:312px; width:532px; height:36px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:7px; text-align:left; background-color:transparent;" ></textarea>
<textarea name="Comments" id="Comments" class="noborder" style="position:absolute; left:114px; top:374px; width:530px; height:69px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:7px; text-align:left; background-color:transparent;" ></textarea>
<input name="MDName" id="MDName" type="text" class="noborder" style="position:absolute; left:236px; top:450px; width:191px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:7px; text-align:left; background-color:transparent;" oscarDB=doctor>
<input name="Specialty" id="Specialty" type="text" class="noborder" style="position:absolute; left:477px; top:448px; width:169px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:7px; text-align:left; background-color:transparent;" value="">
<input name="MDAddress" id="MDAddress" type="text" class="noborder" style="position:absolute; left:136px; top:469px; width:291px; height:17px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:9px; text-align:left; background-color:transparent;" oscarDB=clinic_addressLineFull>
<input name="ClinicTel" id="ClinicTel" type="text" class="noborder" style="position:absolute; left:519px; top:470px; width:127px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:7px; text-align:left; background-color:transparent;" oscarDB=clinic_phone>
<textarea name="DigitalSignature" id="DigitalSignature" class="noborder" style="position:absolute; left:191px; top:489px; width:236px; height:33px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:7px; text-align:left; background-color:transparent;" >Signed digitally in Electronic Medical Record</textarea>
<input name="SignatureDate" id="SignatureDate" type="text" class="noborder" style="position:absolute; left:478px; top:490px; width:142px; height:14px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:7px; text-align:left; background-color:transparent;" value="">
<input name="PtName2" id="PtName2" type="text" class="noborder" style="position:absolute; left:139px; top:872px; width:217px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:7px; text-align:left; background-color:transparent;" oscarDB=first_last_name>
<textarea name="Consent" id="Consent" class="noborder" style="position:absolute; left:391px; top:863px; width:257px; height:55px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:7px; text-align:left; background-color:transparent;" >Consent informed by reading this form; and authorization to release provided verbally to physician and witnessed by MOA</textarea>
<input name="Today" id="Today" type="text" class="noborder" style="position:absolute; left:140px; top:914px; width:215px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:7px; text-align:left; background-color:transparent;" value="">
<input name="PtPhone" id="Ptphone" type="text" class="noborder" style="position:absolute; left:425px; top:920px; width:217px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:10px; text-align:left; background-color:transparent;" oscarDB=phone>
</div>
<div class="DoNotPrint" style="position: absolute; top: 1970px; left: 40px;">
<table>
<tr>
<td class="subjectline">
Description: <input name="subject" size="20" type="text">
<input value="Submit" name="SubmitButton" type="submit">
<input value="Reset" name="ResetButton" type="reset">
<input value="Print" name="PrintButton" type="button" onClick="window.print();">
<input value="Print and Submit" name="PrintSubmitButton" type="button" onClick="window.print();document.forms[0].submit();releaseDirtyFlag()">
</td>
</tr>
</table>
</div>
</body>
</html>
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