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Lilly-PAP-Form.html

HTML contains drop down lists and drawn check boxes.

HTML icon Lilly-PAP-Form.html — HTML, 14 kB (15039 bytes)

File contents

<html>
<head>
<title>Lilly Canada Patient Assistance Program</title>


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


<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" 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>

<!-- js graphics scripts -->
<script type="text/javascript" src="${oscar_image_path}jsgraphics.js"></script>

	<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('Lilly-PAP-Form',document.getElementById('first_last_name').value);	
		}

	</script>
<script language="javascript">
function formPrint(){
	 if (document.getElementById('DrawCheckmark').checked){ 
			printCheckboxes();
	 }else{
			window.print();
	 } 
} 
</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 = 1000;
		top.window.outerWidth = 1000;
		}
		}
		</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 = true;
}
function releaseDirtyFlag(){
		needToConfirm = false; //Call this function if doesn't requires an alert.
//this could be called when save button is clicked
}
window.onbeforeunload = confirmExit;
function confirmExit(){
	 if (needToConfirm){
		 return "You have attempted to leave this page. If you have made any changes to the fields without clicking the Save button, your changes will be lost. Are you sure you want to exit this page?";
	 }
}
</script>

</head>

<body onload="checkGender(); startUp();">
<img id='BGImage' src="${oscar_image_path}Lilly-PAP-Form.png" style="position: absolute; left: 0px; top: 0px; width:750px">
<div id="chkCanvas" style="position:absolute; left:0px; top:0px; width:750; height:750;" onmouseover="putInBack();"></div>

<form method="post" action="" name="FormName" id="FormName" >

<input name="first_last_name" id="first_last_name" type="text" class="noborder" style="position:absolute; left:387px; top:176px; width:326px; height:14px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=first_last_name>


<input name="DOB" id="DOB" type="text" class="noborder" style="position:absolute; left:557px; top:192px; width:156px; height:13px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=dob>


<input name="English1" id="English1" type="checkbox" style="position:absolute; left:385px; top:205px; " checked>


<input name="French1" id="French1" type="checkbox" style="position:absolute; left:424px; top:205px; ">


<input name="PtPhone" id="PtPhone" type="text" class="noborder" style="position:absolute; left:558px; top:208px; width:156px; height:13px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=phone>


<input name="Initial" id="Initial" type="checkbox" style="position:absolute; left:489px; top:221px; ">


<input name="Renew" id="Renew" type="checkbox" style="position:absolute; left:541px; top:221px; ">


<input name="CoverageYes" id="CoverageYes" type="checkbox" style="position:absolute; left:505px; top:245px; ">


<input name="CoverageNo" id="CoverageNo" type="checkbox" style="position:absolute; left:551px; top:245px; ">


<input name="AnnualIncome" id="AnnualIncome" type="text" class="noborder" style="position:absolute; left:437px; top:269px; width:78px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; text-decoration:underline; background-color:transparent;" value="">


<input name="Gross" id="Gross" type="checkbox" style="position:absolute; left:493px; top:294px; ">


<input name="Net" id="Net" type="checkbox" style="position:absolute; left:556px; top:294px; ">


<select id="FamilyMembers" style="position:absolute; left:490px; top:311px; width:119px; height:18px; text-align:center; background-color:transparent;">
	<option>Choose Number of Family Members</option>

        <option> </option>

        <option>1</option>

        <option>2</option>

        <option>3</option>

        <option>4</option>

        <option>5</option>

        <option>6</option>

        <option>7+</option>

</select>
	

<input name="City" id="City" type="text" class="noborder" style="position:absolute; left:387px; top:328px; width:327px; height:13px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;"  oscarDB=city>


<input name="PtSignature" id="PtSignature" type="text" class="noborder" style="position:absolute; left:251px; top:443px; width:237px; height:23px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; text-decoration:underline; background-color:transparent;" value="">


<input name="Date1" id="Date1" type="text" class="noborder" style="position:absolute; left:521px; top:447px; width:172px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=today>


<input name="GuardianName" id="GuardianName" type="text" class="noborder" style="position:absolute; left:236px; top:469px; width:190px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; text-decoration:underline; background-color:white;" value="">


<input name="GuardianRelation" id="GuardianRelation" type="text" class="noborder" style="position:absolute; left:545px; top:470px; width:128px; height:22px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; text-decoration:underline; background-color:white;" value="">


<select id="GuardianRelation" style="position:absolute; left:545px; top:470px; width:128px; height:22px; text-align:center; text-decoration:underline; background-color:transparent;">
	<option>Choose Relationship</option>

        <option> </option>

        <option>Mother</option>

        <option>Father</option>

        <option>Brother</option>

        <option>Sister</option>

        <option>Son</option>

        <option>Daughter</option>

        <option>Grandmother</option>

        <option>Grandfather</option>

        <option>Aunt</option>

        <option>Uncle</option>

        <option>Cousin</option>

</select>
	


<input name="English2" id="English2" type="checkbox" style="position:absolute; left:396px; top:513px; " checked>


<input name="French2" id="French2" type="checkbox" style="position:absolute; left:482px; top:513px; ">


<input name="DoctorName" id="DoctorName" type="text" class="noborder" style="position:absolute; left:341px; top:533px; width:311px; height:26px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=doctor>


<span style="position:absolute; left:655px; top:537px; font-family:sans-serif; font-size:12px;">Last, First</span>


<textarea name="ClinicAddress" id="ClinicAddress" class="noborder" style="position:absolute; left:341px; top:563px; width:371px; height:77px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;"  oscarDB=clinic_address></textarea>


<input name="ClinicPhone" id="ClinicPhone" type="text" class="noborder" style="position:absolute; left:341px; top:644px; width:372px; height:13px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;"  oscarDB=clinic_phone>


<input name="ClinicFax" id="ClinicFax" type="text" class="noborder" style="position:absolute; left:341px; top:659px; width:372px; height:13px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;"  oscarDB=clinic_fax>


<textarea name="Products" id="Products" class="noborder" style="position:absolute; left:23px; top:703px; width:203px; height:55px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" ></textarea>


<textarea name="Dosage" id="Dosage" class="noborder" style="position:absolute; left:231px; top:703px; width:117px; height:55px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" ></textarea>


<textarea name="Strength" id="Strength" class="noborder" style="position:absolute; left:352px; top:703px; width:88px; height:56px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" ></textarea>


<input name="Vial" id="Vial" type="checkbox" style="position:absolute; left:442px; top:715px; ">


<input name="Cartridge" id="Cartridge" type="checkbox" style="position:absolute; left:442px; top:730px; ">


<textarea name="Quantity" id="Quantity" class="noborder" style="position:absolute; left:515px; top:703px; width:198px; height:56px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" ></textarea>


<input name="GenericNotOption" id="GenericNotOption" type="text" class="noborder" style="position:absolute; left:295px; top:763px; width:417px; height:26px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Monday" id="Monday" type="checkbox" style="position:absolute; left:291px; top:790px; ">


<input name="Tuesday" id="Tuesday" type="checkbox" style="position:absolute; left:378px; top:790px; ">


<input name="Wednesday" id="Wednesday" type="checkbox" style="position:absolute; left:472px; top:790px; ">


<input name="Thursday" id="Thursday" type="checkbox" style="position:absolute; left:565px; top:790px; ">


<input name="Friday" id="Friday" type="checkbox" style="position:absolute; left:677px; top:790px; ">


<input name="Signature" id="Signature" type="text" class="noborder" style="position:absolute; left:258px; top:868px; width:200px; height:22px; font-family:sans-serif; font-style:italic; font-weight:bold; font-size:12px; text-align:left; text-decoration:underline; background-color:white;" value="Electronically Signed">


<input name="Date2" id="Date2" type="text" class="noborder" style="position:absolute; left:490px; top:868px; width:150px; height:22px; font-family:sans-serif; font-style:italic; font-weight:bold; font-size:12px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=today>


<input name="PatientGender" id="PatientGender" type="hidden" oscarDB=sex>
<input name="Male" id="Male" type="checkbox" class="noborder" style="position:absolute; left: 385px; top: 190px">
<input name="Female" id="Female" type="checkbox" class="noborder" style="position:absolute; left: 420px; top: 190px">



 <div class="DoNotPrint" id="BottomButtons" style="position: absolute; top:970px; 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);"> 
			<input name="DrawCheckmark" id="DrawCheckmark" type="checkbox" checked><span style="font-family:sans-serif; font-size:12px;">Draw Checkmarks</span> 
	 </td></tr></table>
 </div>
 </form>

<script type="text/javascript">
<!-- Drawing in checkmarks -->
var chkcnv = document.getElementById('chkCanvas');
var chkjg = new jsGraphics(chkcnv);
var chkcnvLeft = parseInt(chkcnv.style.left);
var chkcnvTop = parseInt(chkcnv.style.top);
chkjg.setPrintable(true);
function drawCheckmark(x,y){
var offset = 6;
var x = parseInt(x) + offset;
var y = parseInt(y) + offset;
chkjg.setColor('black');
chkjg.setStroke(3);
		// draws checkmark
		var x1 = x;
		var y1 = y+4;
		var x2 = x1 + 3;
		var y2 = y1 + 4;
		var x3 = x2 + 4;
		var y3 = y2 - 12;
		chkjg.drawLine(x1,y1,x2,y2);
		chkjg.drawLine(x2,y2,x3,y3);
		chkjg.paint();
}
function replaceCheckmarks(){
var f = document.getElementById("FormName");
		 for (var i=0;i<f.length;i++){
				if ((f.elements[i].type == 'checkbox') && (f.elements[i].checked)){
					var a = f.elements[i].style.left;
					var b = f.elements[i].style.top;
					drawCheckmark(a,b);
				}
		 }
}
function printCheckboxes(){
		putInFront();
		replaceCheckmarks();
		window.print();
}
function putInFront(){
		chkcnv.style.zIndex = "999999";	
}
function putInBack(){
		chkcnv.style.zIndex = "-999999";	
}
</script>
</body>
</html>

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