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Sigvaris Prescription HTML

HTML icon SigvarisRx.html — HTML, 22 kB (23290 bytes)

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<html>
<head>
<title>Sigvaris Prescription</title>
<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 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('$%7Boscar_image_path%7D','');
				// page2
				var src2 = document.getElementById('BGImage2').href;
				document.getElementById('BGImage2').href = src2.replace('$%7Boscar_image_path%7D','');

			}
			setDocumentTitle('Sigvaris Prescription',document.getElementById('PtName').value);
			setDefaults();			
		}
		
		function setDocumentTitle(Title,PtName)
		{
			// set document title
			document.title = Title + ' - ' + PtName;					
							
		}
		
		function setDefaults()
		{	            
			// check the newform flag to ensure this is the initial load of the form
			if (document.getElementById("newForm").value == 'True')
			{
				//document.getElementById('').value = 'X';	
			}   
		}

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

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

		function submission()
		{
			setFlag();
			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 
		****************************/
		function changeValue(x)
		{
			if (document.getElementById(x).value == '')
				document.getElementById(x).value = 'X';
			else
				document.getElementById(x).value = '';
		}

		function displayKeyCode(evt,x)
		{
			var charCode = (evt.which) ? evt.which :event.keyCode
			// any key press except tab will constitute a value change to the checkbox
			if (charCode != 9)
			{
				changeValue(x);
				return false;
			}
		}
		</script>


<script language="javascript">
function formPrint(){
			window.print();
} 
</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="startUp();" onMouseDown="showButtons();">
<img id='BGImage' src="${oscar_image_path}Sigvaris-Prescription-1.png" style="position: absolute; left: 0px; top: 0px; width:750px">
<form method="post" action="" name="FormName" id="FormName" >

<a name="BGImage2" id="BGImage2" class="DoNotPrint" style="position: absolute; left:100px; top:25px; font-size:16px;" href="${oscar_image_path}Sigvaris-Prescription-2.png" target="_blank">Information and Disclaimers</a>



<input name="PtName" id="PtName" type="text" class="noborder" style="position:absolute; left:215px; top:98px; width:192px; height:23px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px;text-align:left; text-decoration:underline; background-color:white;"  oscarDB=first_last_name>


<input name="Date" id="Date" type="text" class="noborder" style="position:absolute; left:440px; top:98px; width:160px; height:23px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px;text-align:left; text-decoration:underline; background-color:white;"  oscarDB=today>


<input name="Dx" id="Dx" type="text" class="noborder" style="position:absolute; left:216px; top:122px; width:383px; height:23px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px;text-align:left; text-decoration:underline; background-color:white;" value="">


<input name="Electronically Signed" id="Electronically Signed" type="text" class="noborder" style="position:absolute; left:257px; top:146px; width:149px; height:23px; font-family:sans-serif; font-style:italic; font-weight:normal; font-size:14px;text-align:left; text-decoration:underline; background-color:white;" value="&quot;Electronically Signed&quot;">


<input name="ClinicPhone" id="ClinicPhone" type="text" class="noborder" style="position:absolute; left:450px; top:146px; width:152px; height:23px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px;text-align:left; text-decoration:underline; background-color:white;"  oscarDB=clinic_phone>


<input name="2030" id="2030" type="text" style="position:absolute; left:149px; top:237px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);" >


<input name="Cotton1" id="Cotton1" type="text" style="position:absolute; left:293px; top:237px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);" >


<input name="Transparent1" id="Transparent1" type="text" style="position:absolute; left:408px; top:237px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);" >


<input name="Select1" id="Select1" type="text" style="position:absolute; left:511px; top:237px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);" >


<div style="position: absolute; left:540px; top: 237px; font-size:14px; font-family:Arial; ">


<span >Cushioned Cotton</span>


<input name="Cushion1" id="Cushion1" type="text" style=" width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);" >

<span>Eversheer</span>

<input name="Ever" id="Ever" type="text" style=" width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);" >


</div>



<input name="3040" id="3040" type="text" style="position:absolute; left:149px; top:258px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);" >


<input name="Cotton2" id="Cotton2" type="text" style="position:absolute; left:293px; top:258px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);" >


<input name="Rubber2" id="Rubber2" type="text" style="position:absolute; left:399px; top:258px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);" >


<input name="Comfort2" id="Comfort2" type="text" style="position:absolute; left:502px; top:258px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);" >


<div style="position: absolute; left:530px; top: 258px; font-size:14px; font-family:Arial; ">


<span >Truly Transparent</span>


<input name="Transparent2" id="Transparent2" type="text" style=" width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);" >


</div>


<input name="4050" id="4050" type="text" style="position:absolute; left:149px; top:277px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);" >


<input name="Rubber3" id="Rubber3" type="text" style="position:absolute; left:336px; top:277px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);" >


<div style="position: absolute; left:360px; top: 277px; font-size:14px; font-family:Arial; ">


<span >UlceRx Kit</span>


<input name="Ulcer" id="Ulcer" type="text" style=" width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);" >


</div>





<input name="5060" id="5060" type="text" style="position:absolute; left:149px; top:297px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);" >


<input name="Rubber4" id="Rubber4" type="text" style="position:absolute; left:336px; top:297px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);" >

<table style="position: absolute; left:42px; top:310px;text-align: left; width: 90%;  font-size:14px; font-family:Arial;" border="0" cellpadding="0" cellspacing="0">
<tbody>
<tr>
<td colspan="6"><HR NOSHADE SIZE=5></td>
</tr>
<td><input name="NoSubs" id="NoSubs" type="text" style=" width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);" ></td>
<td><b> No Substitutions   &nbsp</b></td>
<td> Number of Pairs </td>
<td><input name="NumberOfPairs" id="NumberOfPairs" type="text" class="noborder" style=" font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px;text-align:left; text-decoration:underline; background-color:white;"  value="" ></td>
<td>  &nbsp Number of Refills</td>
<td><input name="NumberOfRefills" id="NumberOfRefills" type="text" class="noborder" style=" font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px;text-align:left; text-decoration:underline; background-color:white;"  value="" ></td>
</tbody>
</table>



<input name="Calf" id="Calf" type="text" style="position:absolute; left:149px; top:473px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);" >


<input name="Thigh" id="Thigh" type="text" style="position:absolute; left:223px; top:492px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);" >


<input name="Hose" id="Hose" type="text" style="position:absolute; left:300px; top:473px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);" >


<input name="ThighWith" id="ThighWith" type="text" style="position:absolute; left:374px; top:492px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);" >


<input name="Right" id="Right" type="text" style="position:absolute; left:374px; top:522px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);" >


<input name="Left" id="Left" type="text" style="position:absolute; left:374px; top:540px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);" >


<input name="Maternity" id="Maternity" type="text" style="position:absolute; left:452px; top:473px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);" >


<input name="Arm" id="Arm" type="text" style="position:absolute; left:527px; top:492px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);" >


<input name="Gauntlet" id="Gauntlet" type="text" style="position:absolute; left:527px; top:512px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);" >


<input name="NoGauntlet" id="NoGauntlet" type="text" style="position:absolute; left:527px; top:528px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);" >

<table style="position: absolute; left:42px; top:580px;text-align: left; width: 80%;" border="0" cellpadding="0" cellspacing="0">
<tbody>
<tr>
<td colspan="6">Donning Devices:</td>
</tr>
<tr>
<td><input name="gloves" id="gloves" type="text" style=" width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);" ></td>
<td><span>Rubber Gloves</span></td>
<td><input name="SOS" id="SOS" type="text" style=" width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);" ></td>
<td><span>S.O.S. (Slip On SIGVARIS)</span></td>
<td><input name="slide" id="slide" type="text" style=" width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);" ></td>
<td><span>Easy Slide</span></td>
</tr>
<tr>
<td><input name="underliner" id="underliner" type="text" style=" width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);" ></td>
<td><span>UlceRx Underliner</span></td>
<td><input name="Extensor" id="Extensor" type="text" style=" width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);" ></td>
<td colspan="3"><span>Cornu-Thenard Extensor</span></td>
</tbody>
</table>

<table style="position: absolute; left:42px; top:640px; text-align: left; width: 90%;" border="1" cellpadding="0" cellspacing="0">
<tbody>

<tr>
<td colspan="6">Note: All Sigvaris Stockings are Recommended for Travel</td>
</tr>
<tr>
<td colspan="2"><u>Compression</u></td>
<td colspan="4"><u>Indications</u></td>
                
</tr>
<tr>
<td colspan="2" style="  font-size:10px; font-family:Arial;"><span>20-30 mmHg<span></td>
<td colspan="4" style="  font-size:10px; font-family:Arial;">-Heavy, fatigued, tired, aching legs<br>-Mild varicosities during pregnancy<br>-Mild varicosities with minimal edema<br>-Minimal edema upper extremities<br>-Post-sclerotherapy of small veins</td>
                
</tr>
<tr>
<td colspan="2" style="  font-size:10px; font-family:Arial;"><span>30-40 mmHg<span></td>
<td colspan="4" style="  font-size:10px; font-family:Arial;">-Moderate to severe varicosities with mild edema during pregnancy<br>-Mild varicosities with moderate edema<br>-Post fracture, Post traumatic edema<br>-Post sclerotherapy or phlebectomy of larger veins or after vein stripping to maintain treatment success<br>-CVI Grades I and II*<br>-DVT  or Post Thrombotic Syndrome<br>-Mild primary lymphedema after decongestant therapy to maintain reduction, secondary lymphedema or moderate edema of the upper extremities</td>
                
</tr>

<tr>
<td colspan="2" style="  font-size:10px; font-family:Arial;"><span>40-50 mmHg<span></td>
<td colspan="4" style="  font-size:10px; font-family:Arial;">-Severe varicosities<br>-Severe edema<br>-Primary and reversable lymphedema after decongestant therapy for reduction maintenance<br>-Pronounced CVI (Grades II and III*)<br>-Severe Post traumatic and Post fracture edema<br>-Recurrent venous ulceration (GradeIIIa)<br>-Severe Post Thrombotic Syndrome</td>
                
</tr>

<tr>
<td colspan="2" style="  font-size:10px; font-family:Arial;"><span>50-60 mmHg<span></td>
<td colspan="4" style="  font-size:10px; font-family:Arial;">-Primary lymphedema after decongestant therapy for reduction maintenance<br>-Severe Post Thrombotic Syndrome (PTS)</td>
                
</tr>

</tbody>
</table>






 <!-- The submit/print/reset buttons ------------------------------------------------------------->
<div style="position: absolute; left: 10px; top: 975px;" class="DoNotPrint" id="BottomButtons" >
		<table>
		<tr><td>
		<input type="hidden" id="newForm" name="newForm" value="True" />				
		Subject: <input name="subject" size="40" type="text"> 
		<input value="Submit" name="SubmitButton" id="SubmitButton" type="button" onclick="releaseDirtyFlag();document.FormName.submit()">
		<input value="Reset" name="ResetButton" id="ResetButton" type="reset"> 
		<input value="Print" name="PrintButton" id="PrintButton" type="button" onclick="printLetter()"> 			
		<input value="Print and Submit" name="PrintSubmitButton" type="button" onClick="printSubmit()">
		</td></tr>
		</table>
</div>
<!-- ------End of submit/print/reset buttons----------------------------------------------------->
 </div>
 </form>

</body>
</html>

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