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Generic Allied Health Referral eForm HTML file

HTML icon Allied_Health_V5.html — HTML, 29 kB (30546 bytes)

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<html>
<head>

<!-- Physiotherapy etc referral form - allows for customizing for favourite allied health providers -->

<!-- V1, Jun15_2014 for specific PT locations -->
<!-- V2, Jan14_2016 for NWFP -->
<!-- V3: May15_2016 additional PT site, set width/height limits, off-line architecture, jQuery X-boxes, autopopulate subject, show/hide  -->

<!-- eForm DISCLAIMER: As is: eForms are shared as-is, free of charge on a share-alike basis with absolutely no guarantee or warranty.
 No Quality Control: The author does not vet any eForms and does not purport to apply any manner of quality control.
 Responsibility: The responsibility for the clinical and medical-legal consequences of any and all eForms, rest with the clinical OSCAR end-users themselves, not with the author of the eForm.
 This applies to both eForms shared by others, and those created by users themselves.
 Attribution: eForms are shared freely among the user community, with attribution to the original author of the eForm.
 Free: eForms so shared may not be sold or purchased.
 Provincial validation:  eForms are optional and non-essential add-ons, separate from OSCAR, and with their own license terms.
 eForms are not part of the OSCAR core program functionality and code base.
 For this reason eForms are not subject to provincial validation testing and conformance criteria. 
 eForms are also not subject to the ISO production process for OSCAR. -->

<!-- Do not use apostrophes - they do not allow for proper eForm zip inside Oscar.  Instead, use: &#8217; -->

<link rel="stylesheet" type="text/css" media="print" href="${oscar_image_path}JSMPC.css" />

<!-- 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>
<script language="javascript" src="onBodyLoad.js"></script>

<!-- OSCAR based files for greater functionality -->
<script type="text/javascript" src="${oscar_image_path}jquery-1.7.1.min.js"></script>

<!-- main calendar program -->
<script type="text/javascript" src="../share/calendar/calendar.js"></script>
<script type="text/javascript" src="../share/calendar/lang/calendar-en.js"></script>
<script type="text/javascript" src="../share/calendar/calendar-setup.js"></script>
<link rel="stylesheet" type="text/css" media="all" href="../share/calendar/calendar.css" title="win2k-cold-1" />

<!-- Freeform Signatures -->
<script type="text/javascript" src="${oscar_image_path}jSignature.min.js"></script>
<script type="text/javascript" src="jSignature.min.js"></script>

<!-- script to link to other pages within Oscar -->
<script language="javascript" src="${oscar_image_path}onBodyLoad.js"></script>
<script language="javascript1.2" type="text/javascript" src="onBodyLoad.js"></script>

<style>
input {
	 -moz-box-sizing: content-box;
	 -webkit-print-color-adjust: exact;
	 -webkit-box-sizing: content-box;
	 box-sizing: content-box
}
.sig {
	 border: 2px dotted blue;
	 background: lightgrey;
}
</style>

<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;
	 overflow:hidden;
}
.Show {
	visibility:visible;
	display:inline;
}
.Hide {
	visibility:hidden;
	display:none;
}
.sig {
	 border-style: solid;
	 border-color: transparent;
	 background: transparent;
}
</style>

<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:#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 }
</style>

<style type="text/css">
.noborder {
	 background:transparent;
 }
.Show{
	visibility:visible;
	display:inline;
 }
.Hide{
	visibility:hidden;
	display:none;
 }
</style>

<!-- Xbox styling -->
<style type="text/css">
	.box1 {
		position: absolute;
		width: 16px;
		height: 15px;
		font-size: 15px;
		border: 1px solid #000000;
		cursor: pointer;
		font-weight: bold;
		text-align: center;
		background: yellow;
	}
	.box2 {
		position: absolute;
		width:10px;
		height:9px;
		font-size: 8px;
		border: 1px solid #000000;
		cursor: pointer;
		font-weight: bold;
		text-align: center;
		background: yellow;
	}
	.BoxBorderThick {
		position:absolute;
		border:4px solid #808080;
	} 
	.BoxBorderThin {
		position:absolute;
		border:1px solid #808080;
	} 
</style>

<script language="javascript" type="text/javascript">
		/****************************
		startup functions 
		****************************/
		function startUp() {			
			setDocumentTitle('PT-RMT-DC-Other Referral',document.getElementById('PatientNameL').value);
			setDefaults();

			// Optimize window size/width
			top.window.resizeTo(1100, screen.availHeight) ;

			// Change user name to full First Name, Last Name, and MSP #
			// Get the name and MSP
			var fullName = document.getElementById("current_user_name").value;
			var MSP = document.getElementById("Provider_MSP").value;
	
			// Split the value
			var splitName = fullName.split(",");
			var firstName = "";
			var lastName  = "";
	
			// Check for last name
			if(splitName.length >= 1) {
				lastName = splitName[0].trim();
			}
			if(splitName.length >= 2) {
				firstName = splitName[1].trim();
			}
			var First_Last_Name_MSP = firstName + " " + lastName + ", " + MSP;
	
			// Show the fields on the page
			document.FormName.CurrentProviderDoctorMSP.value = First_Last_Name_MSP ;
		}
		
		function resourceLink(resource, extension) {
			// Takes two arguments -- the base filename and its extension -- and
			// returns a string depending on whether the page has been opened
			// locally or if it has been uploaded to OSCAR.
			//
			// Example usage: resourceLink('image1', 'png')
			// Return value: 'image1.png' or '${oscar_image_path}image1.png'

			var prefix = (window.location.href.toLowerCase().indexOf("http") != -1) ? '${oscar_image_path}' : '';

			if (typeof extension === "undefined") {
				var extension = '';
			} else {
				var extension = '.' + extension;
			}

			return prefix + resource + extension;
		}

		function selectorValue(selectId) {
			return selectId.value;
		}

		function changeImage(img, imgId) {
			// Changes the src value of an <img>.
			document.getElementById(imgId).src = resourceLink(img)
			document.getElementById(imgId).href = resourceLink(img)
		}

		function setDocumentTitle(Title, PatientNameL) {
			// set document title
			document.title = Title + ' - ' + PatientNameL;					
							
		}
		
		function setDefaults() {	            
			// check the newForm flag to ensure this is the initial load of the form
			if (document.getElementById("newForm").value == 'True') {
				document.getElementById('Dr1').value = 'X';	
				document.getElementById('Allied_Clinic').className = 'Hide';
				// CheckCopyTo();
			}
		} 

		/****************************
			submit and print functions 
		****************************/
		function printSubmit() {
			printLetter();
			releaseDirtyFlag();			
			submission();
		}

		function printLetter() {
			// hide the bottom buttons; disabled below
			// if (document.getElementById('BottomButtons').style.display == '')
			// document.getElementById('BottomButtons').style.display = 'none';
			// print the letter
			window.print();
		} 

		function submission() {
			setFlag();
			// add subject on submit - specific to each eForm
			document.FormName.subject.value= document.FormName.Allied_Clinic_text.value + ' ' + document.FormName.Allied_Clinic_text_Other.value; 
			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 
		****************************/
		$( document ).ready(function() {
			$('.XBox').prop("readonly","true");
			$('.XBox').mousedown(function(evt) {
				changeValue(evt.target);
				});
			$('.XBox').keydown(function(evt) {
				displayKeyCode(evt);
			});	
		});

		function changeValue(element) {
			if (element.val == undefined) {
			element = $(element); // Convert to jquery element
		}
			if (element.val() == '') {
			element.val('X');
			}
			else {element.val('');}
		}

		function displayKeyCode(evt) {
			var charCode = evt.which || evt.keyCode;
			// any key press except tab will constitute a value change to the checkbox
			if (charCode != 9) {
				changeValue(evt.target);
				return false;
			}
		}

		function changeYes_No(x) {
			if (document.getElementById(x).value == '')
				document.getElementById(x).value = 'Y';
			else if (document.getElementById(x).value == 'Y')
				document.getElementById(x).value = 'N';
			else
				document.getElementById(x).value = '';
		}

		/****************************
			scripts to confirm closing of window if have not saved yet
		****************************/
			//keypress events trigger dirty flag
			var needToConfirm = true;
			document.onkeyup=setDirtyFlag;
		function setDirtyFlag() {
			needToConfirm = true;
		}

		function releaseDirtyFlag() {
			needToConfirm = false; //Call this function if does not require 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?";
			}
		}

		/****************************
			scripts to show or hide location box
		****************************/
		function Location() {
			if (document.getElementById("LocationDisplay").value != 'none') {
				document.getElementById('Allied_Clinic').className = 'Show';
				document.getElementById('Allied_Clinic_details').className = 'Show';
				document.getElementById('AlliedClinicOption').className = 'Show';
			} else {
				document.getElementById('Allied_Clinic').className = 'Hide';
				document.getElementById('Allied_Clinic_details').className = 'Hide';
				document.getElementById('AlliedClinicOption').className = 'Hide';
			}
		}
</script>

</head>

<body onload="startUp();" onMouseDown="showButtons();">
<form method="post" action="" name="FormName" id="FormName" >

<div id="page1" style="position:relative; left:0px; top:0px; width:850px;">

<input type="hidden" name="LocationDisplay" id="LocationDisplay" value="">

<!-- Hidden input for eForm title -->
<input type="hidden" name="PatientNameL" id="PatientNameL" oscarDB=patient_nameL>
<input type="hidden" name="current_user_name" id="current_user_name" oscarDB=current_user>
<input type="hidden" name="Provider_MSP" id="Provider_MSP" oscarDB=current_user_ohip_no>

<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>
<input name="clinic_name" id="clinic_name" type="text" class="noborder" style="width:850px; border:0px; font-family:Times New Roman; font-size:24pt; text-align:center" oscardb=clinic_name>
<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>


<table class="head">
	<tr><td width="50%" valign="top">
		<input name="Dr1" id="Dr1" type="text" class="Xbox box1"><input name="CurrentProviderDoctorMSP" id="CurrentProviderDoctorMSP" type="text" class="noborder" style="position:relative; left:25px; width:300px; border:0px; font-size:16px" value=""><br>
		<input name="DrOther" id="DrOther" type="text" class="Xbox box1"><input name="DrOtherText" id="DrOtherText" type="text" class="noborder" style="position:relative; left:25px; width:300px; font-size:16px"><br>
		</td>

		<td width="50%" valign="top" align="right">
			<textarea name="clinic_label" class="noborder" style="font-size:16px; width:350px; max-width:450px; height:120px; max-height:160px; text-align:right;" oscarDB=clinic_label></textarea>
	</td></tr>
</table>

<p><input name="Date" id="Date" type="text" class="noborder" style="width:120px; font-family:Arial; font-size:20px; background:white;" oscarDB=Today></p>

<!-- Add allied professionals here; note format -->
<table>
	<tr><td>
		<textarea name="Allied_Clinic" id="Allied_Clinic" style="width:300px; max-width:400px; height:180px; max-height:220px; overflow:hidden; border: 1px solid #000000; font-family:Arial; font-size:16px; font-weight:bold; background:white;" value=""></textarea>
		</td>
		<td class="DoNotPrint"><select name="Location" id="Location" style="color:green;">
			<option>Choose</option>
			<option onClick="
			document.FormName.LocationDisplay.value='none'; 
			Location(); 
			document.FormName.Allied_Clinic.value=''; 
			document.FormName.Allied_Clinic_details.value=''; 
			document.FormName.Allied_Clinic_box.value=''; 
			document.FormName.Allied_Clinic_text.value='';
			document.FormName.Allied_Clinic_box_Other.value=''; 
			document.FormName.Allied_Clinic_text_Other.value=''; 
			">none</option>
			<option></option>

			<option style="color:red;">Generic Options</option>
			<option onClick="
			document.FormName.LocationDisplay.value= 'none'; 
			Location(); 
			document.FormName.Allied_Clinic.value=''; 
			document.FormName.Allied_Clinic_details.value=''; 
			document.FormName.Allied_Clinic_box.value=''; 
			document.FormName.Allied_Clinic_text.value='';
			document.FormName.Allied_Clinic_box_Other.value='X'; 
			document.FormName.Allied_Clinic_text_Other.value='Physiotherapy'; 
			">Physiotherapy</option>
		
			<option onClick="
			document.FormName.LocationDisplay.value= 'none'; 
			Location(); 
			document.FormName.Allied_Clinic.value=''; 
			document.FormName.Allied_Clinic_details.value=''; 
			document.FormName.Allied_Clinic_box.value=''; 
			document.FormName.Allied_Clinic_text.value='';
			document.FormName.Allied_Clinic_box_Other.value='X'; 
			document.FormName.Allied_Clinic_text_Other.value='Massage Therapy'; 
			">RMT</option>
s
			<option onClick="
			document.FormName.LocationDisplay.value= 'none'; 
			Location(); 
			document.FormName.Allied_Clinic.value=''; 
			document.FormName.Allied_Clinic_details.value=''; 
			document.FormName.Allied_Clinic_box.value=''; 
			document.FormName.Allied_Clinic_text.value='';
			document.FormName.Allied_Clinic_box_Other.value='X'; 
			document.FormName.Allied_Clinic_text_Other.value='Chiropractor'; 
			">Chiropractor</option>
	
			<option onClick="
			document.FormName.LocationDisplay.value= 'none'; 
			Location(); 
			document.FormName.Allied_Clinic.value=''; 
			document.FormName.Allied_Clinic_details.value=''; 
			document.FormName.Allied_Clinic_box.value=''; 
			document.FormName.Allied_Clinic_text.value='';
			document.FormName.Allied_Clinic_box_Other.value='X'; 
			document.FormName.Allied_Clinic_text_Other.value='Psychologist'; 
			">Psychologist</option>

			<option onClick="
			document.FormName.LocationDisplay.value= 'none'; 
			Location(); 
			document.FormName.Allied_Clinic.value=''; 
			document.FormName.Allied_Clinic_details.value=''; 
			document.FormName.Allied_Clinic_box.value=''; 
			document.FormName.Allied_Clinic_text.value='';
			document.FormName.Allied_Clinic_box_Other.value='X'; 
			document.FormName.Allied_Clinic_text_Other.value='Podiatry'; 
			">Podiatry</option>

			<option></option>

			<option style="color:red;">Specific Options</option>

			<option onClick="
			document.FormName.LocationDisplay.value= document.FormName.Location.value; 
			Location();
			document.FormName.Allied_Clinic.value='REFERRAL TO: \n\nTrailside Physio \n#280-522 7th St \nNew Westminster, BC, V3M 5T5 \nPhone: 604-522-6319 \n\nhttp://trailsidephysio.com/'; 
			document.FormName.Allied_Clinic_details.value='*Physio, *Massage, *Exercise Program, *Chiropractic, *Acupuncture, *Active Release Techniques'; 
			document.FormName.Allied_Clinic_text.value='Physiotherapy'; 
			document.FormName.Allied_Clinic_box.value='X'; 
			document.FormName.Allied_Clinic_text_Other.value=''; 
			document.FormName.Allied_Clinic_box_Other.value=''; 
			">Trailside NW</option>

			<option onClick="
			document.FormName.LocationDisplay.value= document.FormName.Location.value; 
			Location();
			document.FormName.Allied_Clinic.value='REFERRAL TO: \n\nTrailside Physio \n#144-3000 Lougheed Hwy \nCoquitlam, BC, V3B 1C5 \nPhone: 604-464-5788 \n\nhttp://trailsidephysio.com/'; 
			document.FormName.Allied_Clinic_details.value='*Physio, *Massage, *Exercise Program, *Chiropractic, *Acupuncture, *Active Release Techniques'; 
			document.FormName.Allied_Clinic_text.value='Physiotherapy'; 
			document.FormName.Allied_Clinic_box.value='X'; 
			document.FormName.Allied_Clinic_text_Other.value=''; 
			document.FormName.Allied_Clinic_box_Other.value=''; 
			">Trailside Coq</option>

			<option onClick="
			document.FormName.LocationDisplay.value= document.FormName.Location.value; 
			Location();
			document.FormName.Allied_Clinic.value='REFERRAL TO: \n\nPhysioMoves \n#220-5620-152nd St \nSurrey, BC, V3S 3K2 \nPhone: 604-575-7477 \n\nPanorama Village \n\nhttp://www.physiomoves.com/'; 
			document.FormName.Allied_Clinic_details.value='*Physio, *Sport Rehab, *Massage, *Bike Fit, *Post Surgical Rehab \n\nFax: 778-571-1177'; 
			document.FormName.Allied_Clinic_text.value='Physiotherapy'; 
			document.FormName.Allied_Clinic_box.value='X'; 
			document.FormName.Allied_Clinic_text_Other.value=''; 
			document.FormName.Allied_Clinic_box_Other.value=''; 
			">PhysioMoves - Panorama Village</option>

			<option onClick="
			document.FormName.LocationDisplay.value= document.FormName.Location.value; 
			Location();
			document.FormName.Allied_Clinic.value='REFERRAL TO: \n\nPhysioMoves \n1599- 128th St \nSouth Surrey, BC \nPhone: 604-385-4000 \n\nOcean Park, next to Schill Insurance \n\nhttp://www.physiomoves.com/'; 
			document.FormName.Allied_Clinic_details.value='*Physio, *Sport Rehab, *Massage, *Bike Fit, *Post Surgical Rehab'; 
			document.FormName.Allied_Clinic_text.value='Physiotherapy'; 
			document.FormName.Allied_Clinic_box.value='X'; 
			document.FormName.Allied_Clinic_text_Other.value=''; 
			document.FormName.Allied_Clinic_box_Other.value=''; 
			">PhysioMoves - Ocean Park</option>

			<option onClick="
			document.FormName.LocationDisplay.value= document.FormName.Location.value; 
			Location();
			document.FormName.Allied_Clinic.value='REFERRAL TO: \n\nNew West Sports Medicine \nB1 - 65 Richmond St\nNew Westminster, BC, V3L 5P5 \nPhone: 604-526-1886, www.nwsm.ca'; 
			document.FormName.Allied_Clinic_details.value=''; 
			document.FormName.Allied_Clinic_text.value='Physiotherapy'; 
			document.FormName.Allied_Clinic_box.value='X'; 
			document.FormName.Allied_Clinic_text_Other.value=''; 
			document.FormName.Allied_Clinic_box_Other.value=''; 
			">New West Sports Medicine</option>

			<option onClick="
			document.FormName.LocationDisplay.value= document.FormName.Location.value; 
			Location();
			document.FormName.Allied_Clinic.value='REFERRAL TO: \n\nRoyal City Health & Manual Therapy \nSuite 210 - 610 Sixth St\nNew Westminster, BC, V3L 3C2 \nPhone: 604-524-4446 \n\nhttp://newwestminsterphysiotherapy.com/ \n\ninfo@newwestphysio.com'; 
			document.FormName.Allied_Clinic_details.value='*Physio, *Massage, *Chiropractic, *Dietitian, *Clinical Counselling, *Personal training, *Custom Orthotics'; 
			document.FormName.Allied_Clinic_text.value='Physiotherapy'; 
			document.FormName.Allied_Clinic_box.value='X'; 
			document.FormName.Allied_Clinic_text_Other.value=''; 
			document.FormName.Allied_Clinic_box_Other.value=''; 
			">Royal City Health & Manual Therapy</option>

			<option></option>

			<option onClick="
			document.FormName.LocationDisplay.value= document.FormName.Location.value; 
			Location();
			document.FormName.Allied_Clinic.value='REFERRAL TO: \n\nDr. Roy Mathews \nSuite 603 - 625 Fifth Avenue\nNew Westminster, BC, V3M 1X4 \nPhone: 604-521-7110'; 
			document.FormName.Allied_Clinic_details.value=''; 
			document.FormName.Allied_Clinic_text.value='Podiatry'; 
			document.FormName.Allied_Clinic_box.value='X'; 
			document.FormName.Allied_Clinic_text_Other.value=''; 
			document.FormName.Allied_Clinic_box_Other.value=''; 
			">Dr. R Mathews, DPM</option>

			<option onClick="
			document.FormName.LocationDisplay.value= document.FormName.Location.value; 
			Location();
			document.FormName.Allied_Clinic.value='REFERRAL TO: \n\nFYidoctors \nSuite 240 - 610 Sixth Street\nNew Westminster, BC, V3L 3C2 \nPhone: 604-522-6929 \n2nd Floor, Royal City Centre'; 
			document.FormName.Allied_Clinic_details.value='Fax 604-521-0328'; 
			document.FormName.Allied_Clinic_text.value='Optometry'; 
			document.FormName.Allied_Clinic_box.value='X'; 
			document.FormName.Allied_Clinic_text_Other.value=''; 
			document.FormName.Allied_Clinic_box_Other.value=''; 
			">FYi Optometry</option>

			<option onClick="
			document.FormName.LocationDisplay.value= document.FormName.Location.value; 
			Location();
			document.FormName.Allied_Clinic.value='REFERRAL TO: \n\nKintec \n13465 King George Blvd\nSurrey, BC, V3T 2T8 \nPhone: 604-584-5633 (KNEE)\n(North of 108 Ave)\nwww.kintec.net'; 
			document.FormName.Allied_Clinic_text.value='Sport-Occupational Injury - orthotics'; 
			document.FormName.Allied_Clinic_box.value='X'; 
			document.FormName.Allied_Clinic_text_Other.value=''; 
			document.FormName.Allied_Clinic_box_Other.value=''; 
			">Kintec Surrey</option>

			<option onClick="
			document.FormName.LocationDisplay.value= document.FormName.Location.value; 
			Location();
			document.FormName.Allied_Clinic.value='REFERRAL TO: \n\nKintec \nTwin Rinks 5700 Langley By-Pass\nLangley, BC, V3A 7Z3 \nPhone: 604-533-5633 (KNEE)'; 
			document.FormName.Allied_Clinic_text.value='Sport-Occupational Injury - orthotics'; 
			document.FormName.Allied_Clinic_box.value='X'; 
			document.FormName.Allied_Clinic_text_Other.value=''; 
			document.FormName.Allied_Clinic_box_Other.value=''; 
			">Kintec Langley</option>
	
			<option onClick="
			document.FormName.LocationDisplay.value= document.FormName.Location.value; 
			Location();
			document.FormName.Allied_Clinic.value='REFERRAL TO: \n\nKintec \n#9 - 400 Capilano Rd\nPort Moody, BC, V3H 0E1 \nPhone: 604-800-3338 (FEET)\n(Across from Thrifty Foods)\nwww.kintec.net'; 
			document.FormName.Allied_Clinic_text.value='Sport-Occupational Injury - orthotics'; 
			document.FormName.Allied_Clinic_box.value='X'; 
			document.FormName.Allied_Clinic_text_Other.value=''; 
			document.FormName.Allied_Clinic_box_Other.value=''; 
			">Kintec Pt Moody</option>

			<option onClick="
			document.FormName.LocationDisplay.value= document.FormName.Location.value; 
			Location();
			document.FormName.Allied_Clinic.value='REFERRAL TO: \n\nKintec \n#640 - 22709 Lougheed Hwy\nMaple Ridge, BC, V2X 2V5 \nPhone: 604-463-3338 (FEET)\n(Valleyfair Mall)\nwww.kintec.net'; 
			document.FormName.Allied_Clinic_text.value='Sport-Occupational Injury - orthotics'; 
			document.FormName.Allied_Clinic_box.value='X'; 
			document.FormName.Allied_Clinic_text_Other.value=''; 
			document.FormName.Allied_Clinic_box_Other.value=''; 
			">Kintec Maple Ridge</option>

			<option onClick="
			document.FormName.LocationDisplay.value= document.FormName.Location.value; 
			Location();
			document.FormName.Allied_Clinic.value='REFERRAL TO: \n\nKintec \n#280 - 6091 Gilbert Rd\nRichmond, BC, V7C 5L9 \nPhone: 604-274-3668\n(Opposite Richmond General Hospital)\nwww.kintec.net'; 
			document.FormName.Allied_Clinic_text.value='Sport-Occupational Injury - orthotics'; 
			document.FormName.Allied_Clinic_box.value='X'; 
			document.FormName.Allied_Clinic_text_Other.value=''; 
			document.FormName.Allied_Clinic_box_Other.value=''; 
			">Kintec Richmond</option>

			<option onClick="
			document.FormName.LocationDisplay.value= document.FormName.Location.value; 
			Location();
			document.FormName.Allied_Clinic.value='REFERRAL TO: \n\nKintec \n1201 W. Broadway\nVancouver, BC, V6H 1G7 \nPhone: 604-736-3338 (FEET)\n(Opposite Toys R Us)\nwww.kintec.net'; 
			document.FormName.Allied_Clinic_text.value='Sport-Occupational Injury - orthotics'; 
			document.FormName.Allied_Clinic_box.value='X'; 
			document.FormName.Allied_Clinic_text_Other.value=''; 
			document.FormName.Allied_Clinic_box_Other.value=''; 
			">Kintec Vancouver</option>

			<option onClick="
			document.FormName.LocationDisplay.value= document.FormName.Location.value; 
			Location();
			document.FormName.Allied_Clinic.value='REFERRAL TO: \n\nKintec \n975 Marine Dr\nNorth Vancouver, BC, V7P 1S4 \nPhone: 604-980-5633 (KNEE)\n(Marine & McKay)\nwww.kintec.net'; 
			document.FormName.Allied_Clinic_text.value='Sport-Occupational Injury - orthotics'; 
			document.FormName.Allied_Clinic_box.value='X'; 
			document.FormName.Allied_Clinic_text_Other.value=''; 
			document.FormName.Allied_Clinic_box_Other.value=''; 
			">Kintec North Van</option>

			<option onClick="
			document.FormName.LocationDisplay.value= document.FormName.Location.value; 
			Location();
			document.FormName.Allied_Clinic.value='REFERRAL TO: \n\nKintec \n#1 - 2316 McCallum Rd\nAbbotsford, BC, V2S 3P4 \nPhone: 604-859-2660\nwww.kintec.net'; 
			document.FormName.Allied_Clinic_text.value='Sport-Occupational Injury - orthotics'; 
			document.FormName.Allied_Clinic_box.value='X'; 
			document.FormName.Allied_Clinic_text_Other.value=''; 
			document.FormName.Allied_Clinic_box_Other.value=''; 
			">Kintec Abbotsford</option>
		</select>
		</td>
		<td class="DoNotPrint" >
		<textarea name="Allied_Clinic_details" id="Allied_Clinic_details" class="hide" style="width:370px; max-width:370px; height:180px; max-height:220px; overflow:hidden; border: 1px solid #000000; font-family:Arial; font-size:16px; font-weight:bold; background:white;" value=""></textarea>
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		<td></td><td></td>
	</tr>
</table>

<P><span style="font-size:20px"><b>REFERRAL FOR:</b></span></P>

<table>
	<tr name="AlliedClinicOption" id="AlliedClinicOption" class="Show"><td>
		<input name="Allied_Clinic_box" id="Allied_Clinic_box" type="text" class="Xbox box1">
		<input name="Allied_Clinic_text" id="Allied_Clinic_text" type="text" class="noborder normaltext" style="position:relative; left:25px; width:500px; font-size:20px;" value=""><br>
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	<tr><td>
		<input name="Allied_Clinic_box_Other" id="Allied_Clinic_box_Other" type="text" class="Xbox box1">
		<input name="Allied_Clinic_text_Other" id="Allied_Clinic_text_Other" type="text" class="noborder normaltext" style="position:relative; left:25px; width:500px; font-size:20px;" value=""><br>
	</td></tr>
</table>

<P><span style="font-size:20px"><b>RE:</b></span></P>
<textarea name="PatientLabel" id="PatientLabel" class="noborder" dir="ltr" style="width:450px; max-width:850px; height:100px; max-height:130px; border:0px; font-size:16px;" oscarDB=Label></textarea>
<br>

<p><textarea name="reason" style="width:850px; max-width:850px; height:160px; max-height:280px; overflow:hidden; border: 1px solid #000000; font-family:sans-serif; font-size:24px; background:white;">Comment: </textarea></p>

<p class="small">Our clinic values the relationship we have with our local allied health care practitioners. We are pleased 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. Thank you.</p>

<p class="bold" style="font-size:20px;">Signed:</p>
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	Calendar.setup( { inputField :"Date", ifFormat : "%Y-%m-%d", button : "Date" } );
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