wsib8.html
The eform
wsib8.html
—
HTML,
35Kb
File contents
<HTML>
<HEAD>
<title>WSIB 8</title>
<link rel="stylesheet" type="text/css" title="print2" href="${oscar_image_path}print2.css" />
<link rel="stylesheet" type="text/css" title="print1" href="${oscar_image_path}print1.css" />
<script language="JavaScript">
<!--
top.window.moveTo(0,0);
if (document.all) {
top.window.resizeTo(screen.availWidth,800);
}
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 = 800;
}
}
//-->
</script>
<script language="javascript">
var needToConfirm = false;
document.onkeyup=setDirtyFlag //keypress events trigger dirty flag
window.onbeforeunload = confirmExit;
function setDirtyFlag(){needToConfirm = true; }
function confirmExit() {
if (needToConfirm)
return "You have attempted to leave this page. If you have made any changes to the fields without clicking the Submit button, your changes will be lost. Are you sure you want to exit this page?";
}
</script>
<style type="text/css" media="print">
td.subjectline {
display:none;
}
input.noborder {
border : 0px;
background: transparent;
font-family: monospace;
font-size: 12pt;
text-transform: uppercase;
}
input.small {
border : 0px;
background: transparent;
font-family: monospace;
font-size: 8pt;
text-transform: uppercase;
}
input.large {
border : 0px;
background: transparent;
font-family: monospace;
font-size: 16pt;
text-transform: uppercase;
}
input.spaced {
border : 0px;
background: transparent;
letter-spacing:14px;
font-family: monospace;
font-size: 12pt;
text-transform: uppercase;
}
textarea.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;
//scrollbar : none;
border : 0px;
font-family: monospace;
font-size: 12pt;
text-transform: uppercase;
}
</style>
<style type="text/css">
.style1 {
font-family: arial, sans-serif;
font-size: 10px;
font-weight: normal;
}
</style>
<SCRIPT LANGUAGE="JavaScript">
function FormSetup() {
changeStyle('print1')
}
function changeStyle(css_title) {
var i, link_tag ;
for (i = 0, link_tag = document.getElementsByTagName("link") ; i < link_tag.length ; i++ ) {
if ((link_tag[i].rel.indexOf( "stylesheet" ) != -1) && link_tag[i].title) {
link_tag[i].disabled = true ;
if (link_tag[i].title == css_title) {
link_tag[i].disabled = false ;
}
}
}
}
function pagePrint(title) {
changeStyle(title);
window.print();
}
function checkGender(){
if (document.getElementById('PatientGender').value == 'M'){
document.getElementById('Male').checked = true;
}else if (document.getElementById('PatientGender').value == 'F'){
document.getElementById('Female').checked = true;
}
}
</SCRIPT>
</HEAD>
<body Onload="FormSetup(); SignForm(); checkGender(); ">
<form method="post" action="" name="twoPageForm">
<input type="hidden" name="physician" id="physician" oscarDB=doctor >
<script type="text/javascript">
<!-- here you can substitute your signatures for ours //-->
function SignForm(){
if (document.getElementById('physician').value.indexOf('zapski')>0){
document.getElementById("signature").src = "${oscar_image_path}PHC.png";
}
else if(document.getElementById('physician').value.indexOf('dermott')>0){
document.getElementById("signature").src = "${oscar_image_path}TMD.png";
}
else if(document.getElementById('physician').value.indexOf('urman')>0){
document.getElementById("signature").src = "${oscar_image_path}MCH.png";
}
else {
document.getElementById("signature").src = "${oscar_image_path}BNK.png";
}
}
</script>
<div id="page1" style="position: absolute; left: 0px; top: 0px;" >
<img src="${oscar_image_path}WSIB_8_1.png" width="750">
</div>
<div id="page2" style="position: absolute; left: 0px; top: 0px;" >
<img src="${oscar_image_path}WSIB_8_2.png" width="750">
</div>
<div id="page1">
<input name="Page1_1" id="Page1_1" type="text" class="noborder" style="position:absolute; left:63px; top:70px; width:411px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" oscarDB=patient_nameL>
<input name="Page1_2" id="Page1_2" type="text" class="noborder" style="position:absolute; left:536px; top:70px; width:186px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" oscarDB=patient_nameF>
<input name="init" id="init" type="text" class="noborder" style="position:absolute; left:728px; top:73px; width:18px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">
<input name="Page1_3" id="Page1_3" type="text" class="noborder" style="position:absolute; left:122px; top:102px; width:348px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" oscarDB=address>
<input name="Page1_4" id="Page1_4" type="text" class="noborder" style="position:absolute; left:448px; top:142px; width:30px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" oscarDB=province>
<input name="city" id="city" type="text" class="noborder" style="position:absolute; left:122px; top:136px; width:321px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" oscarDB=city>
<input name="postal" id="postal" type="text" class="noborder" style="position:absolute; left:482px; top:142px; width:95px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" oscarDB=postal>
<input name="tel" id="tel" type="text" class="noborder" style="position:absolute; left:582px; top:143px; width:159px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" oscarDB=phone>
<input name="sin" id="sin" type="text" class="noborder" style="position:absolute; left:6px; top:175px; width:153px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">
<input name="dob" id="dob" type="text" class="noborder" style="position:absolute; left:196px; top:176px; width:145px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" oscarDB=DOBc>
<input name="eng" id="eng" type="checkbox" style="position:absolute; left:465px; top:176px; " checked>
<input name="fr" id="fr" type="checkbox" style="position:absolute; left:515px; top:178px; ">
<input name="business" id="business" type="text" class="noborder" style="position:absolute; left:132px; top:201px; width:605px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">
<input name="bus_add" id="bus_add" type="text" class="noborder" style="position:absolute; left:133px; top:233px; width:603px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">
<input name="bus_city" id="bus_city" type="text" class="noborder" style="position:absolute; left:133px; top:266px; width:309px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">
<input name="bus_prov" id="bus_prov" type="text" class="noborder" style="position:absolute; left:448px; top:267px; width:31px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="ON">
<input name="bus_postal" id="bus_postal" type="text" class="noborder" style="position:absolute; left:483px; top:273px; width:93px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">
<input name="bus_phone" id="bus_phone" type="text" class="noborder" style="position:absolute; left:581px; top:273px; width:154px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" oscarDB=phone2>
<input name="Page1_5" id="Page1_5" type="checkbox" style="position:absolute; left:267px; top:302px; ">
<input name="Page1_6" id="Page1_6" type="checkbox" style="position:absolute; left:321px; top:302px; ">
<input name="Page1_7" id="Page1_7" type="checkbox" style="position:absolute; left:368px; top:302px; ">
<input name="Page1_8" id="Page1_8" type="checkbox" style="position:absolute; left:3px; top:403px; ">
<input name="Page1_9" id="Page1_9" type="checkbox" style="position:absolute; left:102px; top:403px; " checked>
<input name="Page1_10" id="Page1_10" type="checkbox" style="position:absolute; left:203px; top:403px; ">
<input name="Page1_11" id="Page1_11" type="checkbox" style="position:absolute; left:309px; top:403px; ">
<input name="Page1_12" id="Page1_12" type="text" class="noborder" style="position:absolute; left:9px; top:437px; width:545px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" oscarDB=current_user>
<input name="Page1_13" id="Page1_13" type="text" class="noborder" style="position:absolute; left:9px; top:464px; width:543px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" oscarDB=clinic_addressLine>
<input name="city" id="city" type="text" class="noborder" style="position:absolute; left:9px; top:496px; width:253px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" oscarDB=clinic_city>
<input name="clinic_prov" id="clinic_prov" type="text" class="noborder" style="position:absolute; left:272px; top:499px; width:32px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="ON">
<input name="clinic_postal" id="clinic_postal" type="text" class="noborder" style="position:absolute; left:314px; top:500px; width:81px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" oscarDB=clinic_postal>
<input name="clinic_phone" id="clinic_phone" type="text" class="noborder" style="position:absolute; left:406px; top:502px; width:146px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" oscarDB=clinic_phone>
<input name="wsib_provider" id="wsib_provider" type="text" class="noborder" style="position:absolute; left:573px; top:433px; width:170px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">
<input name="Page1_14" id="Page1_14" type="text" class="noborder" style="position:absolute; left:612px; top:464px; width:127px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" oscarDB=today>
<input name="Page1_15" id="Page1_15" type="text" class="noborder" style="position:absolute; left:574px; top:505px; width:166px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">
<input name="acc_date" id="acc_date" type="text" class="noborder" style="position:absolute; left:613px; top:566px; width:130px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">
<textarea name="details" id="details" class="noborder" style="position:absolute; left:4px; top:598px; width:739px; height:101px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" ></textarea>
<input name="Page1_16" id="Page1_16" type="checkbox" style="position:absolute; left:119px; top:726px; " checked>
<input name="Page1_17" id="Page1_17" type="checkbox" style="position:absolute; left:161px; top:726px; ">
<input name="Page1_18" id="Page1_18" type="checkbox" style="position:absolute; left:273px; top:710px; " checked>
<input name="Page1_19" id="Page1_19" type="checkbox" style="position:absolute; left:273px; top:729px; ">
<input name="Page1_20" id="Page1_20" type="checkbox" style="position:absolute; left:362px; top:711px; ">
<input name="Page1_21" id="Page1_21" type="checkbox" style="position:absolute; left:489px; top:711px; ">
<input name="Page1_22" id="Page1_22" type="checkbox" style="position:absolute; left:576px; top:711px; ">
<input name="Page1_23" id="Page1_23" type="checkbox" style="position:absolute; left:6px; top:794px; ">
<input name="Page1_24" id="Page1_24" type="checkbox" style="position:absolute; left:6px; top:806px; ">
<input name="Page1_25" id="Page1_25" type="checkbox" style="position:absolute; left:6px; top:820px; ">
<input name="Page1_26" id="Page1_26" type="checkbox" style="position:absolute; left:6px; top:832px; ">
<input name="Page1_27" id="Page1_27" type="checkbox" style="position:absolute; left:6px; top:850px; ">
<input name="Page1_28" id="Page1_28" type="checkbox" style="position:absolute; left:88px; top:794px; ">
<input name="Page1_29" id="Page1_29" type="checkbox" style="position:absolute; left:88px; top:805px; ">
<input name="Page1_30" id="Page1_30" type="checkbox" style="position:absolute; left:88px; top:818px; ">
<input name="Page1_31" id="Page1_31" type="checkbox" style="position:absolute; left:88px; top:830px; ">
<input name="Page1_32" id="Page1_32" type="checkbox" style="position:absolute; left:179px; top:794px; ">
<input name="Page1_33" id="Page1_33" type="checkbox" style="position:absolute; left:179px; top:805px; ">
<input name="Page1_34" id="Page1_34" type="checkbox" style="position:absolute; left:179px; top:818px; ">
<input name="Page1_35" id="Page1_35" type="checkbox" style="position:absolute; left:179px; top:830px; ">
<input name="Page1_36" id="Page1_36" type="checkbox" style="position:absolute; left:283px; top:805px; ">
<input name="Page1_37" id="Page1_37" type="checkbox" style="position:absolute; left:283px; top:818px; ">
<input name="Page1_38" id="Page1_38" type="checkbox" style="position:absolute; left:283px; top:830px; ">
<input name="Page1_39" id="Page1_39" type="checkbox" style="position:absolute; left:283px; top:842px; ">
<input name="Page1_40" id="Page1_40" type="checkbox" style="position:absolute; left:352px; top:805px; ">
<input name="Page1_41" id="Page1_41" type="checkbox" style="position:absolute; left:352px; top:818px; ">
<input name="Page1_42" id="Page1_42" type="checkbox" style="position:absolute; left:352px; top:830px; ">
<input name="Page1_43" id="Page1_43" type="checkbox" style="position:absolute; left:352px; top:842px; ">
<input name="Page1_44" id="Page1_44" type="checkbox" style="position:absolute; left:393px; top:805px; ">
<input name="Page1_45" id="Page1_45" type="checkbox" style="position:absolute; left:393px; top:818px; ">
<input name="Page1_46" id="Page1_46" type="checkbox" style="position:absolute; left:393px; top:830px; ">
<input name="Page1_47" id="Page1_47" type="checkbox" style="position:absolute; left:492px; top:805px; ">
<input name="Page1_48" id="Page1_48" type="checkbox" style="position:absolute; left:492px; top:818px; ">
<input name="Page1_49" id="Page1_49" type="checkbox" style="position:absolute; left:492px; top:830px; ">
<input name="Page1_50" id="Page1_50" type="checkbox" style="position:absolute; left:535px; top:805px; ">
<input name="Page1_51" id="Page1_51" type="checkbox" style="position:absolute; left:535px; top:818px; ">
<input name="Page1_52" id="Page1_52" type="checkbox" style="position:absolute; left:535px; top:830px; ">
<input name="Page1_53" id="Page1_53" type="checkbox" style="position:absolute; left:535px; top:842px; ">
<input name="Page1_54" id="Page1_54" type="checkbox" style="position:absolute; left:612px; top:805px; ">
<input name="Page1_55" id="Page1_55" type="checkbox" style="position:absolute; left:612px; top:818px; ">
<input name="Page1_56" id="Page1_56" type="checkbox" style="position:absolute; left:612px; top:830px; ">
<input name="Page1_57" id="Page1_57" type="checkbox" style="position:absolute; left:612px; top:842px; ">
<input name="Page1_58" id="Page1_58" type="checkbox" style="position:absolute; left:659px; top:805px; ">
<input name="Page1_59" id="Page1_59" type="checkbox" style="position:absolute; left:659px; top:818px; ">
<input name="Page1_60" id="Page1_60" type="checkbox" style="position:absolute; left:659px; top:830px; ">
<input name="Page1_61" id="Page1_61" type="checkbox" style="position:absolute; left:720px; top:805px; ">
<input name="Page1_62" id="Page1_62" type="checkbox" style="position:absolute; left:720px; top:818px; ">
<input name="Page1_63" id="Page1_63" type="checkbox" style="position:absolute; left:720px; top:830px; ">
<input name="Page1_64" id="Page1_64" type="checkbox" style="position:absolute; left:5px; top:886px; ">
<input name="Page1_65" id="Page1_65" type="checkbox" style="position:absolute; left:5px; top:899px; ">
<input name="Page1_66" id="Page1_66" type="checkbox" style="position:absolute; left:5px; top:912px; ">
<input name="Page1_67" id="Page1_67" type="checkbox" style="position:absolute; left:5px; top:925px; ">
<input name="Page1_68" id="Page1_68" type="checkbox" style="position:absolute; left:5px; top:937px; ">
<input name="Page1_69" id="Page1_69" type="checkbox" style="position:absolute; left:5px; top:949px; ">
<input name="Page1_70" id="Page1_70" type="checkbox" style="position:absolute; left:5px; top:961px; ">
<input name="Page1_71" id="Page1_71" type="checkbox" style="position:absolute; left:5px; top:972px; ">
<input name="Page1_72" id="Page1_72" type="checkbox" style="position:absolute; left:168px; top:886px; ">
<input name="Page1_73" id="Page1_73" type="checkbox" style="position:absolute; left:168px; top:899px; ">
<input name="Page1_74" id="Page1_74" type="checkbox" style="position:absolute; left:168px; top:912px; ">
<input name="Page1_75" id="Page1_75" type="checkbox" style="position:absolute; left:168px; top:925px; ">
<input name="Page1_76" id="Page1_76" type="checkbox" style="position:absolute; left:168px; top:937px; ">
<input name="Page1_77" id="Page1_77" type="checkbox" style="position:absolute; left:168px; top:949px; ">
<input name="Page1_78" id="Page1_78" type="checkbox" style="position:absolute; left:168px; top:961px; ">
<input name="Page1_79" id="Page1_79" type="checkbox" style="position:absolute; left:168px; top:972px; ">
<input name="Page1_80" id="Page1_80" type="checkbox" style="position:absolute; left:339px; top:886px; ">
<input name="Page1_81" id="Page1_81" type="checkbox" style="position:absolute; left:339px; top:899px; ">
<input name="Page1_82" id="Page1_82" type="checkbox" style="position:absolute; left:339px; top:912px; ">
<input name="Page1_83" id="Page1_83" type="checkbox" style="position:absolute; left:339px; top:925px; ">
<input name="Page1_84" id="Page1_84" type="checkbox" style="position:absolute; left:339px; top:937px; ">
<input name="Page1_85" id="Page1_85" type="checkbox" style="position:absolute; left:339px; top:968px; ">
<input name="Page1_86" id="Page1_86" type="checkbox" style="position:absolute; left:496px; top:886px; ">
<input name="Page1_87" id="Page1_87" type="checkbox" style="position:absolute; left:496px; top:899px; ">
<input name="Page1_88" id="Page1_88" type="checkbox" style="position:absolute; left:496px; top:912px; ">
<input name="Page1_89" id="Page1_89" type="checkbox" style="position:absolute; left:494px; top:925px; ">
<input name="Page1_90" id="Page1_90" type="checkbox" style="position:absolute; left:612px; top:886px; ">
<input name="Page1_91" id="Page1_91" type="checkbox" style="position:absolute; left:612px; top:899px; ">
<input name="Page1_92" id="Page1_92" type="checkbox" style="position:absolute; left:612px; top:912px; ">
<input name="Page1_93" id="Page1_93" type="checkbox" style="position:absolute; left:612px; top:925px; ">
<input name="Page1_94" id="Page1_94" type="text" class="noborder" style="position:absolute; left:395px; top:957px; width:340px; height:22px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">
<input name="PatientGender" id="PatientGender" type="hidden" oscarDB=sex>
<input name="Male" id="Male" type="checkbox" class="noborder" style="position:absolute; left: 359px; top: 176px">
<input name="Female" id="Female" type="checkbox" class="noborder" style="position:absolute; left: 398px; top: 176px">
</div>
<div id="page2" >
<input name="claim_p2" id="claim_p2" type="text" class="noborder" style="position:absolute; left:287px; top:11px; width:190px; height:28px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">
<input name="Page2_1" id="Page2_1" type="text" class="noborder" style="position:absolute; left:11px; top:55px; width:310px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" oscarDB=patient_nameL>
<input name="Page2_2" id="Page2_2" type="text" class="noborder" style="position:absolute; left:340px; top:55px; width:222px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" oscarDB=patient_nameF>
<input name="Page2_3" id="Page2_3" type="text" class="noborder" style="position:absolute; left:607px; top:55px; width:137px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" oscarDB=DOBc>
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<input name="dx" id="dx" type="text" class="noborder" style="position:absolute; left:174px; top:358px; width:566px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="" onchange="subject.value=dx.value;">
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<input name="Page2_86" id="Page2_86" type="checkbox" style="position:absolute; left:404px; top:888px; ">
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<div style="position: absolute; left: 80px; top: 940px; z-index:2;">
<img id="signature" src="${oscar_image_path}BNK.png" width="260" height ="40">
</div>
</div>
<div class="DoNotPrint" style="position: absolute; top: 1000px; left: 10px;">
<table>
<tr>
<td class="subjectline">
<input type="button" value="View Page 1" onclick="javascript:changeStyle('print1')" class="button">
<input type="button" value="View Page 2" onclick="javascript:changeStyle('print2')" class="button">
<input type="button" value="Print Page 1" onclick="javascript:pagePrint('print1')" class="button">
<input type="button" value="Print Page 2" onclick="javascript:pagePrint('print2')" class="button"><br>
Description: <input name="subject" size="10" type="text">
<input value="Submit" name="SubmitButton" type="button" onClick="document.twoPageForm.submit()">
<input value="Reset" name="ResetButton" type="reset">
</td>
</tr>
</table>
</div>
</form>
</BODY>
</HTML>
