Physical therapy referral
An eform for referring to physio, massage or chiropractic. Contributed by Jel Coward.
File contents
<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"> <html> <head> <meta http-equiv="CONTENT-TYPE" content="text/html; charset=windows-1252"> <title>referal physmasschiro</title> <style> <!-- @page { size: 8.5in 11in; margin-left: 0.79in; margin-right: 0.79in; margin-top: 0.5in; margin-bottom: 0.5in } body { font-family: "Times New Roman", serif; font-size: 12pt; background-color:#fdfec7 } P { margin-bottom: 0.08in; direction: ltr; color: #000000; widows: 2; orphans: 2 } p.small { margin-right: 0.5in; margin-left: 0.5in; font-family: "Times New Roman", serif; font-size: 10pt } p.bold { margin-bottom: 0.08in; direction: ltr; color: #000000; widows: 2; orphans: 2; font-weight: bold } H1 { font-family: "Times New Roman", serif; font-size:24pt; text-align: center } table.head {width:100%; border-top-style: solid ; border-style: none; font-family: "Times New Roman", serif; font-size: 10pt } .button { font-family: "Times New Roman", serif; font-size: 12pt } textarea { overflow: hidden; border-width: 0; font-family: "Times New Roman", serif; font-size: 12pt } input.noborder { border : 0px; font-family: "Times New Roman", serif; font-size: 12pt } --> </style> <style media="print"> .hide { display:none } </style> </head> <body> <p align="center" style="border-style: double none none; border-color: rgb(0, 0, 0) -moz-use-text-color -moz-use-text-color; border-width: 1.1pt medium medium; padding: 0.02in 0in 0in; margin-bottom: 0in;"></p> <H1>Pemberton Medical Clinic</H1> <p align="center" style="border-style: double none none; border-color: rgb(0, 0, 0) -moz-use-text-color -moz-use-text-color; border-width: 1.1pt medium medium; padding: 0.02in 0in 0in; margin-bottom: 0in;"></p> <br> <form name="form1" method="post" action=""> <table class="head"> <tr> <td width="50%" valign="top"> <input type="checkbox" name="C1" value="ON">Dr. Hugh Fisher 03877<br> <input type="checkbox" name="C2" value="ON">Dr. Rebecca Lindley 26399<br> <input type="checkbox" name="C3" value="ON">Dr. Marisa Collins 07067<br> <input type="checkbox" name="C4" value="ON">Dr. Jel Coward 27015 </td> <td width="50%" valign="top" align="right">Box 69, Pemberton, B.C. V0N 2L0 <br> Phone 604-894-6454<br> Fax 604-894-6721 </td> </tr> </table> <p> <br> <input type="text" name="date" size="20" oscarDB=Today class=noborder> <br> </p> <p class="bold"> REFERRAL FOR:<br><br> <input type="checkbox" name="C5" value="ON">Physiotherapy<br><br> <input type="checkbox" name="C6" value="ON">Massage<br><br> <input type="checkbox" name="C7" value="ON">Chiropractic<br></p> <p></p> <textarea cols="50" rows="5" name="label" dir="ltr" oscarDB=Label></textarea> <br> <p> <textarea name=reason cols="100" rows="15" wrap=physical></textarea> </p> <p class="small"> At the Pemberton Medical Clinic, we value the relationship we have with our local allied health care practitioners and are happy to refer our patients for care. We recognize that in the course of treatment, different symptoms or signs may present. We request that if you believe a patient could benefit from additional investigations, referrals, etc. you please send them back to our office for reassessment and further management. </p> <p class="bold">Signed:</p> <br> <br> <br> <p class="hide"> <input type="submit" value="Submit" name="B1" class="button"> <input type="button" value="Print" onclick="javascript:window.print()" class="button"> <br> <input type="button" value="Close Window" onclick="javascript:self.close();" onkeypress="javascript:self.close();" class="button"></p> </form> </body> </html>
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