ÿþ<!DOCTYPE html PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN" "http://www.w3.org/TR/html4/loose.dtd"> <html> <head> <meta name="generator" content="CoffeeCup Visual Site Designer, Version 7.0 Build 24 for Windows"> <meta http-equiv="Content-Type" content="text/html;charset=utf-8"> <meta http-equiv="generator" content="CoffeeCup Visual Site Designer (www.coffeecup.com)"> <meta name="created" content="Wed, 28 Sep 2011 20:49:37 GMT"> <title> Online Scheduling </title> <style type="text/css"> /* TEXT STYLES */ .textstyle0 {font-family:Arial;font-weight:normal;font-style:normal;font-size:15px;text-decoration:none;color:#00909e;} .textstyle1 {font-family:Arial;font-weight:normal;font-style:normal;font-size:15px;text-decoration:none;color:#000000;} .textstyle2 {font-family:Arial;font-weight:bold;font-style:normal;font-size:23px;text-decoration:none;color:#000000;} /* OBJECT STYLES */ div.Object45013 { position:absolute; top:48px; left:674px; z-index:0; } div.Object45014 { position:absolute; top:32px; left:0px; z-index:1; } div.Object45015 { position:absolute; top:678px; left:0px; z-index:2; } div.Object45016 { position:absolute; padding-right:5px; top:131px; left:898px; z-index:3; text-align:right; width:46px; } div.Object45017 { position:absolute; padding-right:5px; top:9px; left:16px; z-index:4; text-align:left; width:114px; } div.Object45018 { position:absolute; padding-right:5px; top:8px; left:153px; z-index:5; text-align:left; width:104px; } div.Object45019 { position:absolute; padding-right:5px; top:8px; left:282px; z-index:6; text-align:left; width:129px; } div.Object45020 { position:absolute; padding-right:5px; top:161px; left:868px; z-index:7; text-align:right; width:76px; } div.Object45021 { position:absolute; padding-right:5px; top:191px; left:860px; z-index:8; text-align:right; width:85px; } div.Object45022 { position:absolute; padding-right:5px; top:221px; left:796px; z-index:9; text-align:right; width:149px; } div.Object45023 { position:absolute; padding-right:5px; top:251px; left:825px; z-index:10; text-align:right; width:120px; } div.Object45024 { position:absolute; padding-right:5px; top:281px; left:797px; z-index:11; text-align:right; width:148px; } div.Object45025 { position:absolute; padding-right:5px; top:2px; left:815px; z-index:12; text-align:right; width:148px; } div.Object45026 { position:absolute; padding-right:5px; top:8px; left:434px; z-index:13; text-align:left; width:93px; } /* BODY STYLES */ body { margin:0px; padding :0px; text-align:center; height:100%; width:100%; background-color: #ffffff; } /* LINK STYLES */ A:link { color:#0000ff;} A:visited { color:#0000ff;} A:hover { color:#00ff00;} /* IMAGE STYLES */ img { border:0 none} /* CONTAINER RULES */ #container { position:relative; margin:0px auto 0 auto; height:700px; width:960px; text-align:left; padding-left:0px;} </style> </head> <body> <div id="container"> <div class="Object45013"><img src="files/excel.jpg" alt="" width="262px" height="67px"></div> <div class="Object45014"><img src="files/IMG_28.jpg" alt="" width="960px" height="8px"></div> <div class="Object45015"><img src="files/IMG_28.jpg" alt="" width="960px" height="8px"></div> <div class="Object45016"><span class="textstyle0"><a href="index.html">Home<br> </a></span></div> <div class="Object45017"><span class="textstyle1"><a target="_blank" href="https://webportal2.excelmedicalimaging.com/Portal.Web/Account/LogOn?ReturnUrl=%2fPortal.Web">Physician Login<br> </a></span></div> <div class="Object45018"><span class="textstyle1"><a target="_blank" href="http://www.excelmedicalimaging.com/rx">Referral Sheet<br> </a></span></div> <div class="Object45019"><span class="textstyle0">Online Scheduling<br> </span></div> <div class="Object45020"><span class="textstyle1"><a href="modalities.html">Modalities<br> </a></span></div> <div class="Object45021"><span class="textstyle1"><a href="procedures.html">Procedures<br> </a></span></div> <div class="Object45022"><span class="textstyle1"><a href="acceptedinsurances.html">Accepted Insurances<br> </a></span></div> <div class="Object45023"><span class="textstyle1"><a href="ourradiologists.html">Our Radiologists<br> </a></span></div> <div class="Object45024"><span class="textstyle1"><a href="contactanddirections.html">Contact &#38; Directions<br> </a></span></div> <div class="Object45025"><span class="textstyle2">727.841.8212<br> </span></div> <div class="Object45026"><span class="textstyle1"><a href="videoconference.html">Web Consult<br> </a></span></div> <!-- #################################################### --> <form method="POST" action="sendform.php"> <table cellpadding="3" cellspacing="0" border="0" style="position: absolute; left: 16px; top: 50px; width: 450px; border: 0; font-family:Arial; font-size:12px;"> <tr> <td colspan="2"> Dear Doctor,<br><br> Please enter your patient's information here. Our staff will contact your patient and schedule an appointment as soon as we receive this information. </td> </tr> <tr> <td colspan="2" align="center" style="border: solid #455e7c 2px; background-color: #17375e; color: white;"> REFERRING ENTITY </td> </tr> <tr> <td nowrap>Referring Physician:</td> <td style="width: 100%;"><input name="ReferringPhysician" type="text" style="width: 97%; border: solid #99b163 2px; font-family:Arial;"></td> </tr> <tr> <td nowrap>Phone Number:</td> <td style="width: 100%;"><input name="ReferringPhoneNumber" type="text" style="width: 97%; border: solid #99b163 2px; font-family:Arial;" onchange=" v=this.value.replace(/[^\d]/,''); if(v.length==10){ this.value='('+ v.substring(0,3)+ ') '+v.substring(3,6)+ '-'+v.substring(6);} else{ alert('Wrong format');}"></td> </tr> <tr> <td nowrap>Email:</td> <td style="width: 100%;"><input name="ReferringEmail" type="text" style="width: 97%; border: solid #99b163 2px; font-family:Arial;"></td> </tr> <tr> <td colspan="2" align="center" style="border: solid #455e7c 2px; background-color: #17375e; color: white;"> PATIENT INFO </td> </tr> <tr> <td nowrap>Name:</td> <td style="width: 100%;"><input name="PatientName" type="text" style="width: 97%; border: solid #99b163 2px; font-family:Arial;"></td> </tr> <tr> <td nowrap>Phone Number:</td> <td style="width: 100%;"><input name="PatientPhoneNumber" type="text" style="width: 97%; border: solid #99b163 2px; font-family:Arial;" onchange=" v=this.value.replace(/[^\d]/,''); if(v.length==10){ this.value='('+ v.substring(0,3)+ ') '+v.substring(3,6)+ '-'+v.substring(6);} else{ alert('Wrong format');}"></td> </tr> <tr> <td nowrap>Email:</td> <td style="width: 100%;"><input name="PatientEmail" type="text" style="width: 97%; border: solid #99b163 2px; font-family:Arial;"></td> </tr> <tr> <td nowrap>Preferred Week Day:</td> <td style="width: 100%;"> <input name="Monday" type="checkbox" id="Monday">&nbsp;<label for="Monday">M</label>&nbsp;&nbsp;&nbsp; <input name="Tuesday" type="checkbox" id="Tuesday">&nbsp;<label for="Tuesday">T</label>&nbsp;&nbsp;&nbsp; <input name="Wednesday" type="checkbox" id="Wednesday">&nbsp;<label for="Wednesday">W</label>&nbsp;&nbsp;&nbsp; <input name="Thursday" type="checkbox" id="Thursday">&nbsp;<label for="Thursday">TH</label>&nbsp;&nbsp;&nbsp; <input name="Friday" type="checkbox" id="Friday">&nbsp;<label for="Friday">F</label> </td> </tr> <tr> <td nowrap>Preferred Time:</td> <td style="width: 100%;"> <input name="PreferredTime" type="radio" value="AM" id="AM">&nbsp;<label for="AM">AM</label>&nbsp;&nbsp;&nbsp; <input name="PreferredTime" type="radio" value="PM" id="PM">&nbsp;<label for="PM">PM</label> </td> </tr> <tr> <td nowrap>Reason for Exam:</td> <td style="width: 100%;"><input name="ChiefComplaint" type="text" style="width: 97%; border: solid #99b163 2px; font-family:Arial;"></td> </tr> <tr> <td nowrap>Exam:</td> <td style="width: 100%;"><input name="Modality" type="text" style="width: 97%; border: solid #99b163 2px; font-family:Arial;"></td> </tr> <tr> <td nowrap valign="top">Additional Comments:</td> <td style="width: 100%;"> <textarea name="Comments" style="width: 97%; height: 50px; border: solid #99b163 2px; font-family:Arial; font-size:15px;"></textarea> </td> </tr> <tr> <td nowrap>&nbsp;</td> <td style="width: 100%;"><input type="submit" value="SEND" style="font-family:Arial; font-size:12px; border: solid #455e7c 2px; background-color: #17375e; color: white;"></td> </tr> </table> </form> <!-- #################################################### --> </div> </body> </html>