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PrenatalUS.html

HTML icon PrenatalUS.html — HTML, 11 kB (11874 bytes)

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<html>
<head>
<title>Imaging Requisition - Hospital - Prenatal U/S</title>
<!-------Script to maximize window on loading----------->
<script language="JavaScript1.2">
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top.window.moveTo(0,0);
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top.window.outerHeight = screen.availHeight;
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//-->
</script>
<!-- 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 : 0px;
}

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

</head>

<body width="750px">
<div style="position: absolute; left: 12px; top: 16px;">
     <IMG SRC="${oscar_image_path}XrayHospital.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="MedicalImagingForm">

<!-- ----------------------------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>

<!-- top left -->
<div style="position: absolute; left: 119px; top: 111px;"> 
	<input name="HospitalSite" class="noborder" style="width: 149px; font-family: Arial; font-size: 12px; text-align: center;" type="text" >
</div>
<div style="position: absolute; left:106px; top: 140px;"> 
	<input name="ApptDate" class="noborder" style="width: 168px; font-family: Arial; font-size: 12px; text-align: center;"  type="text">
</div>

<div style="position: absolute; left: 87px; top: 200px;"> 
	<input name="Language" class="noborder"  value=English style="width: 168px; font-family: Arial; font-size: 12px; text-align: center;" type="text">
</div>
<div style="position: absolute; left: 146px; top: 175px;">
        <input name="InterpreterNeededYes" type="checkbox">
</div>
<div style="position: absolute; left: 198px; top: 175px;">
        <input name="InterpreterNeededNo" type="checkbox" checked>
</div>

<!-- top right label -->

<div style="position: absolute; left: 320px; top: 50px;"> 
	<input name="TodaysDate" class="noborder"  oscardb=today style="width: 110px; font-family: Arial; font-size: 12px; text-align: center;"  type="text">
</div>
<div style="position: absolute; left: 444px; top: 50px;"> 
	<input name="DateRequired" class="noborder" style="width: 120px; font-family: Arial; font-size: 12px; text-align: center;"  type="text">
</div>
<div style="position: absolute; left: 573px; top: 50px;"> 
	<input name="DateReceived" class="noborder"  oscardb=today style="width: 110px; font-family: Arial; font-size: 12px; text-align: center;"  type="text">
</div>

<div style="position: absolute; left: 320px; top: 80px;"> 
	<input name="PatientSex" type="text" class="noborder" style="width: 73px; font-family: Arial; font-size: 12px; text-align: center;" oscardb=sex >
</div>
<div style="position: absolute; left: 400px; top: 80px;"> 
	<input name="PatientSurname,FirstName" type="text" class="noborder" style="width: 280px; font-family: Arial; font-size: 12px;" oscarDB=patient_name >
</div>
<div style="position: absolute; left: 320px; top: 110px;"> 
	<input name="Patient_1_Line_Address" type="text" class="noborder" style="width: 360px; font-family: Arial; font-size: 12px;" oscardb=addressLine >
</div>
<div style="position: absolute; left: 320px; top: 170px;"> 
	<input name="DateOfBirth" type="text" class="noborder" style="width: 210px; font-family: Arial; font-size: 12px; text-align: center;" oscardb=dob >
</div>
<div style="position: absolute; left: 540px; top: 138px;"> 
	<input name="PatientHomePhone" type="text" class="noborder" style="width: 140px; font-family: Arial; font-size: 12px; text-align: center;" oscardb=phone>
</div>

<div style="position: absolute; left: 540px; top: 167px;"> 
	<input name="PatientWorkPhone" class="noborder" type="text" style="width: 140px; font-family: Arial; font-size: 12px; text-align: center;" oscardb=phone2>
</div>
<div style="position: absolute; left: 320px; top: 197px;"> 
	<input name="MSP/PHN#" type="text" class="noborder" style="width: 210px; font-family: Arial; font-size: 12px; text-align: center;" oscardb=HIN>
</div>
<div style="position: absolute; left: 540px; top: 197px;"> 
	<input name="Claim#" type="text" class="noborder" style="width: 140px; font-family: Arial; font-size: 12px; text-align: center;">
</div>
<!-- Bill to: -->
<div style="position: absolute; left: 314px; top: 220px;">
	<input name="BillToMSP" type="checkbox" tabindex="1" class="noborder">
</div>
<div style="position: absolute; left: 367px; top: 220px;">
	<input name="BillToWCB" type="checkbox" tabindex="3" class="noborder">
</div>
<div style="position: absolute; left: 414px; top: 220px;">
	<input name="BillToICBC" type="checkbox" tabindex="2" class="noborder">
</div>

<div style="position: absolute; left: 470px; top: 220px;">
	<input name="BillToPatient" type="checkbox" tabindex="4" class="noborder">
</div>
<div style="position: absolute; left: 540px; top: 220px;">
	<input name="BillToOther" type="checkbox" tabindex="5" class="noborder">
</div>
<div style="position: absolute; left: 600px; top: 220px;"> 
	<input class="noborder" name="BillToOtherText" style="width: 80px; font-family: Arial; font-size: 12px;" tabindex="6" type="text">
</div>





<!-- Modality -->
<div style="position: absolute; left: 117px; top: 267px;">
        <input name="Xray" type="checkbox">
</div>
<div style="position: absolute; left: 200px; top: 267px;">
        <input name="Ultrasound" type="checkbox" checked>
</div>
<div style="position: absolute; left: 335px; top: 267px;">
        <input name="CT" type="checkbox">
</div>
<div style="position: absolute; left: 400px; top: 267px;">
        <input name="SpecialProcedures" type="checkbox">
</div>

<div style="position: absolute; left: 155px; top: 305px;">
	<input name="ExamRequestedText" class="noborder" value= "Routine Prenatal 18 week Ultrasound" style="width: 525px; font-family: Arial; font-size: 12px; text-align: center;"  type="text">
</div>


<div style="position: absolute; left: 47px; top: 335px;"> 
	<textarea name="RelevantHistoryText" class="noborder"  style="height: 75px; width: 630px; font-family: Arial; font-size: 12px;" > Pregnant </textarea>
</div>

<div style="position: absolute; left: 207px; top: 417px;">
        <input name="PregnantYes" type="checkbox" checked>
</div>
<div style="position: absolute; left: 257px; top: 417px;">
        <input name="PregantNo" type="checkbox">
</div>

<div style="position: absolute; left: 429px; top: 420px;"> 
	<input name="LMP" class="noborder"  style="width: 230px; font-family: Arial; font-size: 12px; text-align: center;"  type="text">
</div

<div style="position: absolute; left: 206px; top: 443px;"> 
	<input name="Allergies" class="noborder"  style="width: 450px; font-family: Arial; font-size: 12px; text-align: center;"  type="text">
</div


<div style="position: absolute; left: 210px; top: 463px;">
        <input name="DiabeticYes" type="checkbox">
</div>
<div style="position: absolute; left: 253px; top: 463px;">
        <input name="DiabeticNo" type="checkbox" checked>
</div>
<div style="position: absolute; left: 553px; top: 463px;">
        <input name="MetforminYes" type="checkbox">
</div>
<div style="position: absolute; left: 602px; top: 463px;">
        <input name="MetforminNo" type="checkbox" checked>
</div>
<div style="position: absolute; left: 210px; top: 478px;">
        <input name="DialysisYes" type="checkbox">
</div>
<div style="position: absolute; left: 253px; top: 478px;">
        <input name="DialysisNo" type="checkbox" checked>
</div>

<div style="position: absolute; left: 308px; top: 493px;">
        <input name="AnticoagulantYes" type="checkbox">
</div>
<div style="position: absolute; left: 352px; top: 493px;">
        <input name="AnticogulantNo" type="checkbox" checked>
</div>

<div style="position: absolute; left: 380px; top: 480px;"> 
	<input name="Creatinine" class="noborder"  style="width: 120px; font-family: Arial; font-size: 12px; text-align: center;"  type="text">
</div>
<div style="position: absolute; left: 555px; top: 480px;"> 
	<input name="CreatinineDate" class="noborder"  style="width: 120px; font-family: Arial; font-size: 12px; text-align: center;" type="text">
</div>
<!------------------------>
<div style="position: absolute; left:130px; top: 521px; font-size:12px ">
     <b>"Electronically signed"</b>
</div>

<div style="position: absolute; left: 83px; top: 553px;"> 
	<input name="Current Provider Doctor" class="noborder" oscardb=provider_name style="width: 170px; font-family: Arial; font-size: 12px; text-align: center;" tabindex="10" type="text">
</div>
<div style="position: absolute; left: 306px; top: 553px;"> 
	<input name="BillingNumber" class="noborder" style="width: 60px; font-family: Arial; font-size: 12px; text-align: center;"  type="text">
</div>
<div style="position: absolute; left:107px; top: 585px;"> 
	<input name="Clinic phone" class="noborder" oscardb=clinic_phone style="width: 245px; font-family: Arial; font-size: 12px; text-align: center;"  type="text">
</div>

<div style="position: absolute; left: 107px; top: 616px;"> 
	<input name="CopiesTo" class="noborder" style="width: 245px; font-family: Arial; font-size: 12px; text-align: center;"  type="text">
</div>

<div style="position: absolute; left: 583px; top: 525px;">
        <input name="RelevantFilmYes" type="checkbox">
</div>
<div style="position: absolute; left: 632px; top: 525px;">
        <input name="RelevantFilmNo" type="checkbox" checked>
</div>
<div style="position: absolute; left: 442px; top: 553px;"> 
	<input name="DateOfPreviousFilm" class="noborder" style="width: 240px; font-family: Arial; font-size: 12px; text-align: center;" type="text">
</div>

<div style="position: absolute; left: 442px; top: 582px;"> 
	<input name="LocationOfPreviousFilm" class="noborder" style="width: 240px; font-family: Arial; font-size: 12px; text-align: center;"  type="text">
</div>



<!-- --------------------------------------------------------------------- -->
<!-- The submit/print/reset buttons -->
<div class="DoNotPrint" style="position: absolute; top: 920px; 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.MedicalImagingForm.submit()">
		</td>
	</tr>
</table>
</div>
</form>
</body></html>

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