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SickNote.html

You can customize the "Doctor 1", "Doctor 2", etc, with names of people in your practice.

HTML icon SickNote.html — HTML, 3 kB (3469 bytes)

File contents

<html>
<head>
<title>Sick Note</title>

<style type="text/css" media="print">
.DoNotPrint {
	display: none;
}

.noborder {
	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;
	border : 0px;
}
</style>

<style type="text/css">
input.title {
	font-family: Arial;
	font-size: 24;
	font-weight: bolder;
	color: #000000;
	background: #ffffff;
	text-align: center;
	width:100%;
}

.normaltext {
	font-family: Arial;
	font-size: 14;
	text-align: left;
}

.smallertext {
	font-family: Arial;
	font-size: 12;
	text-align: left;
}
</style>

</head>

<body>

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

<table width="750" style="border-style:solid; border-width:3">
<tr>
	<td colspan=4>
		<input name="ClinicName" type="text" class="noborder" style="font-size:30; width: 100%; text-align:center;" oscardb=clinic_name >
	</td>
</tr>
<tr>
	<td colspan=4 align="center">
		<input name="ClinicAddressLine" type="text" class="noborder" style="font-size:10; width:100%; text-align: center;" oscarDB=clinic_addressLineFull>
	</td>
</tr>
<tr align="center">
	<td colspan="4" align="center" class="noborder" style="font-size:10;">
		 Ph: <input name="ClinicPhone" type="text" class="noborder" style="font-size:10; text-align:left; width:75;" oscarDB=clinic_phone>
		 Fax: <input name="ClinicFax" type="text" class="noborder" style="font-size:10; text-align:left; width:75;" oscarDB=clinic_fax>
	</td>
</tr>

</table>

<br>
<div class="normaltext">
	<input name="Dr1" type="checkbox">Doctor 1<br>	//replace 'Doctor #' with your own name(s)
	<input name="Dr2" type="checkbox">Doctor 2<br>
	<input name="Dr3" type="checkbox">Doctor 3<br>
	<input name="Dr4" type="checkbox">Doctor 4<br>
	<input name="DrOther" type="checkbox"><input name="DrOtherText" type="text" class="noborder normaltext" style="width: 200;"><br>
</div>

<br>
<br>

<input name="TodayDate" class="noborder normaltext" type="text" style="width: 300" oscarDB=today >
<br>
<br>

<div class="normaltext" style="font-weight:bold">
To Whom This May Concern:
</div>

<br>
<div class="normaltext">
<input name="PatientName" class="noborder normaltext" type="text" style="width:400;" oscarDB=patient_name>
</div>
<br>
<textarea name="Comments" class="noborder normaltext" style="height: 200; width:700;"></textarea>

<br>
<br>

<div class="normaltext">
Signed:
</div>


<!-- The submit/print/reset buttons 

------------------------------------------------------------->
<div class="DoNotPrint" style="position: absolute; left: 41px;">
<table>
	<tr>
		<td>
			Subject: <input name="subject" size="40" type="text">
			<input value="Submit" name="B1" type="submit">
			<input value="Reset" name="B2" type="reset">
			<input value="Print" onclick="window.print()" type="button">
			<input value="Print and Submit" name="PrintSubmitButton" type="button" onClick="window.print(); document.FormName.submit()">
		</td>
	</tr>
</table>
</div>
</form>
<!-- ------End of submit/print/reset buttons----------------------------------------------------->


</body>
</html>

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