Location: PHPKode > projects > TherapyDoc > therapydoc_1.3.1_3/view/referrals/input_form.php
<?
session_start();
if(!$_SESSION['myusername']){
	header("location:../index.php");
}
include 'globals.inc';
$a=$_SESSION['data_entry'];
if($a==1) {
}
elseif($a==0) {
	header("location:http://$sname/therapydoc/noauth.php");
}
require_once "connect.inc";
include '../../classes/therapydoc/select_lists.php';
?>
<html>
<head>
<link href="../../CSS/main.css" rel="stylesheet" type="text/css">
<script language="javascript" src="../../classes/calendar/calendar.js"></script>
<script language="JavaScript"
	src="../../classes/therapydoc/validation/referral_form.js"></script>
<script type="text/javascript" src="../../classes/therapydoc/menu.js"></script>
</head>
<body id="main_body">
<div id="wrapper"><?php include '../../classes/therapydoc/menu.php';?>
<h1>Enter New Referral Information</h1>
<form method="post" name="referral_form" action="insert_referral.php"
	onClick="return checkForm();">

<table class="forms">
	<tr>
		<td><label for="p_lookup">Referring Physician</label></td>
		<td><?
		p_lookup($dbh);
		?></td>
		<td><label for="l_lookup">Facility</label></td>
		<td><?
		l_lookup($dbh);
		?></td>
	</tr>
	<tr>
		<td><label for="referral_date">Referral Date</label></td>
		<td><?php
		require_once('../../classes/calendar/tc_calendar.php');
		$myCalendar1 = new tc_calendar("date", true);
		$myCalendar1->setIcon("../../classes/images/iconCalendar.gif");
		$myCalendar1->setPath("../../classes/calendar/calendar_form.php");
		$myCalendar1->setDate($today_day, $today_month, $today_year);
		$myCalendar1->writeScript();
		?></td>
		<td><label for="discipline">Disciplines</label></td>
		<td name="discipline"><span> <input id="pt" name="pt" value="1"
			type="checkbox"> <label for="pt">PT</label> </span> <span> <input
			id="ot" name="ot" value="1" type="checkbox"> <label for="ot">OT</label>
		</span> <span> <input id="st" name="st" value="1" type="checkbox"> <label
			for="st">ST</label> </span></td>
	</tr>
	<tr>
		<td colspan="4" class="center"><label>Patient Information</label>
	
	</tr>
	<tr>
		<td><label for="lname">Last Name</label></td>
		<td><input id="lname" name="lname" class="txt" size="25" value=""
			type="text"></td>
		<td><label for="fname">First Name</label></td>
		<td><input id="fname" name="fname" class="txt" size="25" value=""
			type="text"></td>
	</tr>
	<tr>
		<td><label for="add1">Address Line 1</label></td>
		<td><input id="add1" name="add1" class="txt" size="30" value=""
			type="text"></td>
		<td><label for="add2">Address Line 2</label></td>
		<td><input id="add2" name="add2" class="txt" size="30" value=""
			type="text"></td>
	</tr>
	<tr>
		<td><label for="city">City</label></td>
		<td><input id="city" name="city" class="txt" size="30" value=""
			type="text"></td>
		<td><label for="state">State</label></td>
		<td><input id="state" name="state" class="txt" size="10" maxlength="3"
			value="" type="text"></td>
	</tr>
	<tr>
		<td><label for="zip">Zip Code</label></td>
		<td><input id="zip" name="zip" class="txt" maxlength="15" size="15"
			value="" type="text"></td>
		<td><label for="phone">Phone</label></td>
		<td><input id="phone" name="phone" class="txt" maxlength="15" value=""
			type="text"></td>
	</tr>
	<tr>
		<td><label for="email">Email</label></td>
		<td><input id="email" name="email" class="txt" size="30" value=""
			type="text"></td>
		<td><label for="existing">Existing Patient?</label></td>
		<td><select class="txt" id="existing" name="existing">
			<option value="" selected="selected"></option>
			<option value="Yes">Yes</option>
			<option value="No">No</option>
		</select></td>
	</tr>
	<tr>
		<td><label for="birth_date">Birth Date</label></td>
		<td><?php
		$myCalendar2 = new tc_calendar("birthdate", true);
		$myCalendar2->setIcon("../../classes/images/iconCalendar.gif");
		$myCalendar2->setPath("../../classes/calendar/calendar_form.php");
		$myCalendar2->writeScript();
		?></td>
	</tr>
	<tr>
		<td colspan="4" class="center"><label>Payor Information</label></td>
	</tr>
	<tr>
		<td><label for="payor1">Primary Payor</label></td>
		<td><? payor1_lookup($dbh); ?></td>
		<td><label for="payor2">Secondary Payor</label></td>
		<td><? payor2_lookup($dbh); ?></td>
	</tr>
	<tr>
		<td colspan="4" class="center"><input name="submit" type="submit"
			value="Finished"><input name="add_phys" type="submit"
			value="Add Physician"></td>
	</tr>
</table>
</form>
<script language="JavaScript">
new validateForm(document.forms.referral_form);
</script>

</body>
</html>
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