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Blood Products Consent form html

HTML icon Blood Products Consent.html — HTML, 7 kB (8077 bytes)

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<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN" "http://www.w3.org/TR/html4/loose.dtd">
<html>
<head>
<meta http-equiv="Content-Type" content="text/html; charset=UTF-8">
<title>WinRho Consent</title>

<script src="${oscar_image_path}functions.js"></script>
<script type = "text/javascript">
var startX = 750 		//set x offset of topbar in pixels
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<link rel="stylesheet" href="${oscar_image_path}eforms.css" media="screen" type="text/css" charset="utf-8"/>
<link rel="stylesheet" href="${oscar_image_path}eforms-print.css" media="print" type="text/css" />
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<link href="${oscar_image_path}datepicker.css" rel="stylesheet" type="text/css"/> 
	<script type = "text/javascript">
		$(function()
			{
				$("#datepicker").datepicker({dateFormat: 'd M yy'}).val;
				$('#date').datepicker({dateFormat: 'd M yy'});			});
	</script>
<!---------end: DATEPICKER-------------------------------------------------------------->
<!---------PAGE LINKS-------------------------------------------------------------->
<script>
function onBodyLoad()
{
var re = new RegExp( "[?&]" + 'demographic_no' + "=([^&$]*)", "i" );
var offset=window.opener.location.search.search(re);
if(offset==-1){ 
re = new RegExp( "[?&]" + 'demographicNo' + "=([^&$]*)", "i" );
offset=window.opener.location.search.search(re);
}
var pathArray=window.opener.location.pathname.split('/');
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}
function doIFrameOnLoad()
{
var re = new RegExp( "[?&]" + 'demographic_no' + "=([^&$]*)", "i" );
var offset=window.opener.location.search.search(re);
if(offset==-1){ 
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offset=window.opener.location.search.search(re);
}
var demographic=RegExp.$1;
//alert(demographic);
}
function MWlabreq()
{
window.open("../eform/efmformadd_data.jsp?fid=422&demographic_no="+RegExp.$1+"&apptProvider=&appointment=");
}
function WinRho()
{
window.open("../eform/efmformadd_data.jsp?fid=431&demographic_no="+RegExp.$1+"&apptProvider=&appointment=");
}
</script>
<!---------end: PAGE LINKS-------------------------------------------------------------->

<style type="text/css">
<!--
.editable {	font-size: 14px;
}
-->
</style>
</head>
<body>

<div id="container">
<div id="letterFormat">

<form method="post" action="" name="FormName">
<!-------------------------E-FORM HEADER STARTS HERE -------------------->	
 <table width = "740">
  <thead>
	<tr>
     <th valign="top"><div align="left"><img src="${oscar_image_path}pomlogo.gif" alt="logo" width="260" height="130" /></div></th>
        <th width="15%">&nbsp;</th>
        <th colspan="2" nowrap="nowrap" class="right note">
        	2647 East Hastings Street<br />
               Vancouver, B.C. V5K 1Z5<br />
               <span class="fixed">T</span> : 604 255 5556<br />
	           <span class="fixed">F</span> : 604 255 5576<br />
               <em>www.pomegranate-midwives.com</em>		  </th>
	  </tr>
	</thead>
<!-------------------------E-FORM CONTENT STARTS HERE -------------------->	
	<tbody>
	   <tr>
		 <td colspan="6"></td>
		</tr>
<!-------------------------DATE LABEL  -------------------->	
		<tr>
		 <td colspan="7" class = "underlineBottomofRow"><br/><span class="strong">DATE:</span><input name="todaysdate"  type="text" class="OscarFilled"  oscardb=today /><br/>	     </td>
	    </tr>
<!-------------------------PATIENT LABEL CONTENT STARTS HERE -------------------->	
		<tr>
		  <td colspan="7" class="vert-bottom">
		  <span class="strong">PATIENT:</span>          </td>
		</tr>
		<tr>
		  <td colspan="2">
           <input name="patientname" type="text" size="50" class="OscarFilled" oscardb=patient_name />
	       <input name="patientaddress" type="text" size="50" class="OscarFilled" oscardb=addressLine />          </td>		
	      <td width="31%" nowrap="nowrap">
           <div align="right">
            Home:<input name="patientphone1" type="text" class="OscarFilled" oscardb=phone /><br/>
	        Cell:</span><input name="patientphone3" type="text" class="OscarFilled" oscardb=cell />	      
           </div>          </td>
	      <td>&nbsp;</td>
	      <td width="1%" colspan="2">&nbsp;</td>
	    </tr>
		<tr>
		  <td colspan="4" class = "underlineBottomofRow" >
           DOB:</span><input name="patientdob" type="text" class="OscarFilled" oscardb=DOBc /><br />
           PHN:</span><input name="patienthin" type="text" class="OscarFilled" oscardb=HIN />          </td>		
		  <td colspan="2">&nbsp;</td>
	    </tr>
<!-------------------------end: PATIENT LABEL -------------------->	
		<tr>
		  <td colspan="6" class="underlineBottomofRow">
          <BR>
          <span class="strong">PATIENT CONSENT FOR RHESUS IMMUNE GLOBULIN IN PREGNANCY:</span>
            <div align="justify">
             <p>Registered Midwife
              <input name="MW" type="text" class="OscarFilled centered" size="15" oscardb=provider_name_first_init />
              has advised me that, in the course of my pregnancy I may be advised to have an injection of Rhesus Immune Globin. </p>
            <p>I have received information about the benefits and risks associated with this therapy. I have been informed that this is a human blood product collected from volunteer blood donors who have been carefully screened by medical history and sensitive laboratory tests in order to minimize the risk of infectious disease transmission. I understand that this product has also been chemically treated to inactivate blood borne viruses and there are no synthetic substitutes available.
            <p>I have been given the opportunity to ask questions.</p>
            <p>I consent to the injection of Rhesus Immune Globulin.</p>
            <p> PATIENT SIGNATURE:</P>
            <p>&nbsp;</P>
		  </TR>
		<tr>
		  <td colspan="6" class="underlineBottomofRow"><p class="strong">&nbsp;</p>
		    <p class="strong">REGISTERED MIDWIFE:		      </p>
		    <P>I have discussed the benefits of Rhesus Immune Globulin therapy with the patient.
            <P> MIDWIFE SIGNATURE:            
            <p>&nbsp;</p>
            </TR>
		<tr>
		  <td colspan="6" ><p>&nbsp;</p>
	      <p>This form will remain valid for the duration of the pregnancy and for three weeks thereafter.         		  </p>		  </TR>
		

	</tbody>
</table>
</form>

</div>
</div>


<!-- -----------Floating Controls Box ------------------->
<div id="topbar" class="DoNotPrint">
 
	<form name="LazyForm">
	  <p><br/>
	    <input value="OPEN: MW Lab Req" type="button"  onClick="onBodyLoad();MWlabreq();" ><br>
	    <input value="OPEN: Rx WinRho" type="button"  onClick="onBodyLoad();WinRho();" >
      </p>
	  <p><br/>
      </p>
	  <p>
	    <input value="Reset Form" name="ResetButton" id="ResetButton" type="reset" onClick="document.FormName.reset()"><BR>
	    <input value="Print/Fax & Save" name="PrintSubmitButton" id="PrintSubmitButton" type="button" onclick="formPrint();setTimeout('SubmitButton.click()',1000);">
	  </p>
	  <p><br/>
        </p>
  </form>
    
</div>

</body>
</html>

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