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CBSPrenatalScreen.html

HTML icon CBSPrenatalScreen.html — HTML, 9 kB (10200 bytes)

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<html>
<head>
<title> Canadian Blood Services - Prenatal Screening</title>

<!-- ---Script to maximize 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 = screen.availHeight;
top.window.outerWidth = screen.availWidth;
}
}
//-->
</script>
<!----------End maximizing window scipt------------------------------------------------------->

<!-- CSS Script that removes textarea and textbox borders when printing ----------------->
<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-width : 0px;

}
</style>
<!-- ----------------------------------------------------------------------------------------- -->

</head>

<body width="750px">
<div style="position: absolute; left: 12px; top: 16px;">
	<img src="${oscar_image_path}CBSPrenatalScreen.png" width="700">
</div>
<!-- You can remove ${oscar_image_path} as you develop the form, but make sure you put it back before uploading to OSCAR otherwise the image wouldn't show.
<!-- Also note: the image filename IS CASE SENSITIVE INCLUDING THE EXTENSION. It may work otherwise in Windows, but not in OSCAR because it's based on a Linux platform -->


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

<!-- ----------------------------All textfields/checkboxes/textareas go here...---------------- -->


<div style="position: absolute; left: 500px; top: 0px;"> 
	<input name="ClinicName" type="text" class="noborder" style="width: 200px; font-family: Arial; font-size: 12px;font-weight: bold; text-align: center;" oscardb=clinic_name >
</div>

<!-- Request -->
<div style="position: absolute; left: 239px; top: 107px;">
        <input name="Prenatal" type="checkbox">
</div>
<div style="position: absolute; left: 347px; top: 107px;">
        <input name="Infertility" type="checkbox">
</div>
<div style="position: absolute; left: 459px; top: 107px;">
        <input name="RequestOther" type="checkbox">
</div>
<div style="position: absolute; left: 520px; top: 105px;"> 
	<input name="RequestOtherText" type="text" class="noborder" style="width: 150px; font-family: Arial; font-size: 12px; text-align: center;">
</div>

<!-- Blood Collected From -->
<div style="position: absolute; left: 239px; top: 138px;">
        <input name="Mother" type="checkbox">
</div>
<div style="position: absolute; left: 320px; top: 138px;">
        <input name="Father" type="checkbox">
</div>
<div style="position: absolute; left: 394px; top: 138px;">
        <input name="Cord" type="checkbox">
</div>
<div style="position: absolute; left: 459px; top: 138px;">
        <input name="CollectedFromOther" type="checkbox">
</div>
<div style="position: absolute; left: 520px; top: 136px;"> 
	<input name="CollectedFromOtherText" type="text" class="noborder" style="width: 150px; font-family: Arial; font-size: 12px; text-align: center;">
</div>

<!-- Specimen Collected-->
<div style="position: absolute; left: 166px; top: 189px;"> 
	<input name="CollectedDate" type="text" class="noborder" style="width: 140px; font-family: Arial; font-size: 12px; text-align: center;">
</div>
<div style="position: absolute; left: 353px; top: 189px;"> 
	<input name="CollectedFacility" type="text" class="noborder" style="width: 100px; font-family: Arial; font-size: 12px; text-align: center;">
</div>
<div style="position: absolute; left: 353px; top: 209px;"> 
	<input name="CollectedBy" type="text" class="noborder" style="width: 100px; font-family: Arial; font-size: 12px; text-align: center;">
</div>

<!-- Mother's Information -->
<div style="position: absolute; left: 58px; top: 242px;"> 
	<input name="PatientSurname" type="text" class="noborder" oscarDB=patient_nameL style="width: 170px; font-family: Arial; font-size: 12px;" >
</div>
<div style="position: absolute; left: 280px; top: 242px;"> 
	<input name="PatientFirstName" type="text" class="noborder" oscarDB=patient_nameF style="width: 170px; font-family: Arial; font-size: 12px;">
</div>	
<div style="position: absolute; left: 58px; top: 269px;"> 
	<input name="DateOfBirth" type="text" class="noborder" style="width: 170px; font-family: Arial; font-size: 12px; text-align: center;" oscardb=dob >
</div>
<div style="position: absolute; left: 280px; top: 269px;"> 
	<input name="MSP_PHN" type="text" class="noborder" style="width: 170px; font-family: Arial; font-size: 12px; text-align: center;" oscardb=HIN>
</div>
<div style="position: absolute; left: 140px; top: 295px;"> 
	<input name="PatientMaidenName" type="text" class="noborder"  style="width: 190px; font-family: Arial; font-size: 12px;">
</div>	

<!-- EDC-->
<div style="position: absolute; left: 59px; top: 320px;"> 
	<input name="EDC" type="text" class="noborder" style="width: 170px; font-family: Arial; font-size: 12px;" >
</div>

<!-- Hospital for Delivery -->
<div style="position: absolute; left: 180px; top: 355px;"> 
	<input name="HospitalForDelivery" type="text" class="noborder" style="width: 190px; font-family: Arial; font-size: 12px;">
</div>	

<!-- Father's Information -->
<div style="position: absolute; left: 58px; top: 405px;"> 
	<input name="FatherSurname" type="text" class="noborder" style="width: 170px; font-family: Arial; font-size: 12px;" >
</div>
<div style="position: absolute; left: 280px; top: 405px;"> 
	<input name="FatherFirstName" type="text" class="noborder" style="width: 170px; font-family: Arial; font-size: 12px;">
</div>
<div style="position: absolute; left: 58px; top: 433px;"> 
	<input name="FatherDOB" type="text" class="noborder" style="width: 170px; font-family: Arial; font-size: 12px;" >
</div>
<div style="position: absolute; left: 280px; top: 433px;"> 
	<input name="FatherPHN" type="text" class="noborder" style="width: 170px; font-family: Arial; font-size: 12px;">
</div>

<!-- Mail Report To -->
<div style="position: absolute; left: 58px; top: 465px;"> 
	<input name="CurrentProviderDoctor" type="text" class="noborder"  style="width: 170px; font-family: Arial; font-size: 12px; text-align: center;"  oscardb=provider_name>
</div>
<div style="position: absolute; left:75px; top:510px;">
	<textarea name="ClinicAddress" class="noborder" style="height: 45; width: 160; font-family: Arial; font-size: 10px; background: white; " oscarDB=clinic_address></textarea>
</div>
<div style="position: absolute; left: 167px; top: 552px;"> 
	<input name="ClinicPhone" class="noborder" type="text" style="width: 63px; font-family: Arial; font-size: 10px; text-align: center;" oscardb=clinic_phone>
</div>

<!-- Mail Copy To -->
<div style="position: absolute; left: 280px; top: 465px;"> 
	<input name="CCName" type="text" class="noborder"  style="width: 170px; font-family: Arial; font-size: 12px; text-align: center;"  >
</div>
<div style="position: absolute; left:297px; top:510px;">
	<textarea name="CCAddress" class="noborder" style="height: 45; width: 160; font-family: Arial; font-size: 10px; background: white; " ></textarea>
</div>
<div style="position: absolute; left: 389px; top: 552px;"> 
	<input name="CCPhone" class="noborder" type="text" style="width: 63px; font-family: Arial; font-size: 10px; text-align: center;" >
</div>

<!-- Must be completed by physician -->
<div style="position: absolute; left: 465px; top: 289px;">
        <input name="AbNo" type="checkbox">
</div>
<div style="position: absolute; left: 491px; top: 289px;">
        <input name="AbYes" type="checkbox">
</div>
<div style="position: absolute; left: 581px; top: 288px;"> 
	<input name="Ab" class="noborder" type="text" style="width: 100px; font-family: Arial; font-size: 12px; text-align: center;" >
</div>
<div style="position: absolute; left: 598px; top: 312px;"> 
	<input name="AbRefNumber" class="noborder" type="text" style="width: 80px; font-family: Arial; font-size: 12px; text-align: center;" >
</div>

<div style="position: absolute; left: 466px; top: 359px;">
        <input name="RhoGamNo" type="checkbox">
</div>
<div style="position: absolute; left: 504px; top: 359px;">
        <input name="RhoGamYes" type="checkbox">
</div>
<div style="position: absolute; left: 581px; top: 361px;"> 
	<input name="RhoGamDate" class="noborder" type="text" style="width: 100px; font-family: Arial; font-size: 12px; text-align: center;" >
</div>

<div style="position: absolute; left: 466px; top: 404px;">
        <input name="AmnioNo" type="checkbox">
</div>
<div style="position: absolute; left: 504px; top: 404px;">
        <input name="AmnioYes" type="checkbox">
</div>
<div style="position: absolute; left: 581px; top: 406px;"> 
	<input name="AmnioDate" class="noborder" type="text" style="width: 100px; font-family: Arial; font-size: 12px; text-align: center;" >
</div>

<!-- The submit/print/reset buttons ------------------------------------------------------------->
<div class="DoNotPrint" style="position: absolute; top: 620px; 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.CBSPrenatalScreenForm.submit()">
		</td>
	</tr>
</table>
</div>
</form>
<!-- ------End of submit/print/reset buttons----------------------------------------------------->
</body></html>

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