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Physiotherapy Referral Form - generic template

HTML icon Physiotherapy Referral Generic.html — HTML, 9 kB (9322 bytes)

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<html>

<head>
<title>Physiotherapy Referral</title>
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<style type="text/css" media="print">
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        background: transparent;
        overflow: hidden;

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</style>
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<script language="JavaScript1.2">
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</head>

<body width="750px">
<div style="position: absolute; left: 12; top: 16; z-index:'-1'">

<form method="POST" action="">

<p style="margin-bottom: 0cm;" align="center"><big><font style="font-size: 16pt;" size="3"<big>PHYSIOTHERAPY</big></font></big></p>


<p style="margin-bottom: 0cm; text-align: left;">

<font size="1"><span style="font-weight: bold; font-style: italic;"> Date:&nbsp;</span>
<input name="TodayDate" class="noborder normaltext" style="width: 150px" oscardb=today type="text"> 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
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&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;

<input name="WCB"type="checkbox"><span style="font-weight: bold; font-style: italic;"> WCB &nbsp;&nbsp; 
<input name="ICBC"type="checkbox"><span style="font-weight: bold; font-style: italic;"> ICBC &nbsp;&nbsp;
<input name="Other"type="checkbox"><span style="font-weight: bold; font-style: italic;"> Other&nbsp; &nbsp;<br>
</font></p>

<p style="margin-bottom: 0cm;" align="justify"><font size="1">

<span style="font-weight: bold; font-style: italic;"> Patient Name: &nbsp;</span>
<input name="PatientName" class="noborder normaltext" style="width: 280px" oscardb=first_last_name type="text">
&nbsp;&nbsp;

<span style="font-weight: bold; font-style: italic;"> DOB: &nbsp;</span>
<input name="DOB" class="noborder normaltext" style="width: 150px" oscardb=dob type="text">
&nbsp;&nbsp;

<span style="font-weight: bold; font-style: italic;"> PHN: &nbsp;</span>
<input name="PHN" class="noborder normaltext" style="width: 120px" oscardb=HIN type="text"> 

</font></p>
 

<p style="margin-bottom: 0cm;" align="justify"><font size="1"><span style="font-weight: bold; font-style: italic;"> Diagnosis - Reason for Referral: </span></font></p>
<textarea style="height:100; width:750; font-size:14px; font-weight:normal" wrap="normal" cols="1" rows="5" name="Diagnosis"></textarea>


<p style="margin-bottom: 0cm;"><font size="1"><span style="font-weight: bold; font-style: italic;">Contraindications - Restrictions:</span></font></p>
<textarea style="height:50; width:750; font-size:14px; font-weight:normal" wrap="normal" cols="1" rows="2" name="Contraindications"></textarea>


<p style="margin-bottom: 0cm;"><font size="1"><span style="font-weight: bold; font-style: italic;">Diagnostic Imaging:</span></font></p>
<textarea style="height:50; width:750; font-size:14px; font-weight:normal" wrap="normal" cols="1" rows="2" name="DiagnosticImaging"></textarea>
<br>


<p style="margin-bottom: 0cm;"><font size="1"><span style="font-weight: bold; font-style: italic;">Referring Physician:&nbsp;</span>
<input name="CurrentUser" class="noborder normaltext" style="width: 220px" oscardb=current_user type="text"></font>
&nbsp;

<font size="1"><span style="font-weight: bold; font-style: italic;">MSP: &nbsp;</span>
<input name="CurrentUserMSPnumber" class="noborder normaltext" style="width: 80px" oscardb=current_user_ohip_no type="text"></font>
&nbsp;

<font size="1"><span style="font-weight: bold; font-style: italic;">Clinic: &nbsp;</span>
<input name="ClinicName" class="noborder normaltext" style="width: 215px" oscardb=clinic_name type="text"></font>
&nbsp;
</p>

<!-- Modify the paragraphs below to insert the physiotherapy clinic contact details of the practioners in your area -->

<p style="margin-bottom: 0cm;"><input name="FirstPhysioClinic"type="checkbox">
<font size="2"><span style="font-weight: bold; font-style: italic;">Name of first Physio clinic goes here</span>&nbsp;&nbsp; Name of contact person goes here: &nbsp; <a href="http://thePhysiotherapyClinicWebsiteURLgoeshere.com">Name of the URL goes here</a><br>
Address and physical location goes here TEL: (604) ###-#### </font></p>


<p style="margin-bottom: 0cm;"><input name="SecondPhysioClinic"type="checkbox">
<font size="2"><span style="font-weight: bold; font-style: italic;">Name of second Physio clinic goes here</span>&nbsp;&nbsp; Name of contact person goes here: &nbsp; <a href="http://thePhysiotherapyClinicWebsiteURLgoeshere.com">Name of the URL goes here</a><br>
Address and physical location goes here TEL: (604) ###-#### </font></p>

<p style="margin-bottom: 0cm;"><input name="ThirdPhysioClinic"type="checkbox">
<font size="2"><span style="font-weight: bold; font-style: italic;">Name of third Physio clinic goes here</span>&nbsp;&nbsp; Name of contact person goes here: &nbsp; <a href="http://thePhysiotherapyClinicWebsiteURLgoeshere.com">Name of the URL goes here</a><br>
Address and physical location goes here TEL: (604) ###-#### </font></p>

<p style="margin-bottom: 0cm;"><input name="FourthPhysioClinic"type="checkbox">
<font size="2"><span style="font-weight: bold; font-style: italic;">Name of fourth Physio clinic goes here</span>&nbsp;&nbsp; Name of contact person goes here: &nbsp; <a href="http://thePhysiotherapyClinicWebsiteURLgoeshere.com">Name of the URL goes here</a><br>
Address and physical location goes here TEL: (604) ###-#### </font></p>

<p style="margin-bottom: 0cm;"><input name="FifthPhysioClinic"type="checkbox">
<font size="2"><span style="font-weight: bold; font-style: italic;">Name of fifth Physio clinic goes here</span>&nbsp;&nbsp; Name of contact person goes here: &nbsp; <a href="http://thePhysiotherapyClinicWebsiteURLgoeshere.com">Name of the URL goes here</a><br>
Address and physical location goes here TEL: (604) ###-#### </font></p>


<p style="margin-bottom: 0cm;" align="right"><font size="1">
<br>
<br>
<span style="font-weight: normal; font-style: italic;">__________________ &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</span><br>
<span style="font-weight: bold; font-style: italic;">Signature &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</span></font></p>




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<div style="position: relative;">
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     <tr>
        <td class="subjectline">
             Subject: <input type="text" name=subject size="40">&nbsp;
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             <input type="reset" value="Reset" name="B2">
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</form>

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