dentalvisitactivity-pack/static/templates/referral-template.html

Interactive to recreate a pediatric dental visit

<div class="row info-header">
    <div class="col-xs-12">
        <h3 class="step-4">Step 4. Dietitian Referral</h3>
        <div class="instructions"><p>Nick returns to you 5 months later with additional tooth pain. Again, you notice he has been snacking on chips and is holding a bottle of green sports drink. Recently, you were speaking to a colleague who has started to refer his patients to a registered dietitian. After determining Nick will require additional restorative treatment, you decide he and his mother may benefit from more extensive nutritional counseling and decide to give the referral a try.</p></div>
    </div>
</div>

<div class="row row-nopadding">
    <div class="col-xs-4">
        <div class="alert alert-success" role="alert" <% if (!referral.complete) { %> style="display:none"<% }%>>
            Referral Complete
        </div>
        <div class="find-a-dietician well">
            <p><b>Find a Registered Dietitian </b></p>
            <ol>
            <li>Visit <a href="http://www.eatright.org/programs/rdfinder/" target="_blank">EatRight.org</a>&nbsp;</li>
            <li>Locate a dietitian by entering your zip code </li>
            <li>Fill out a referral form with goals for Nick&rsquo;s visit</li>
            <li>Click <b>Refer</b></li>
            </ol>
            <p><a href="http://www.eatright.org/programs/rdfinder/"></a></p>

        </div>
        <div class="patient-chart referral center-block">
             <div class="patient-chart-text"></div>
        </div>
    </div>
    <div class="col-xs-8">
        <div class="referral-form">
            <div class="referral-form-prescription">
                <div class="practice-logo">Pediatric Dental Smiles<br />Referral Form</div>
                <div class="rx_patient">
                    <p><b>PATIENT</b><br />
                    <b>Name:</b> Nick Williams<br />
                    <b>DOB:</b> 03/12/2007<br />
                    <b>Gender:</b> Male<br />
                    <b>Phone #:</b> (817) 555-4444<br />
                    </p>
                </div>
                <form class="form-horizontal">
                    <div class="form-group">
                        <label class="col-xs-4 control-label">Today's Date:</label>
                        <div class="col-xs-8">
                            <div><input type="text" class="form-control" name="theDate"
                                value="<%=referral.theDate%>"></div>
                            <div class="error-block">This field is required</div>
                        </div>
                    </div>
                    <div class="form-group">
                        <label class="col-xs-4 control-label">Referring to:</label>
                        <div class="col-xs-8">
                            <div><input type="text" class="form-control" name="to"
                                value="<%=referral.to%>"></div>
                            <div class="error-block">This field is required</div>
                        </div>
                    </div>
                    <div class="form-group">
                        <label class="col-xs-4 control-label">Referring dentist:</label>
                        <div class="col-xs-8">
                            <div><input type="text" class="form-control" name="from"
                                value="<%=referral.from%>"></div>
                            <div class="error-block">This field is required</div>
                        </div>
                    </div>
                    <div class="form-group">
                        <label class="col-xs-4 control-label">Reason for referral:</label>
                        <div class="col-xs-8">
                            <textarea class="form-control" name="reason"><%= referral.reason %></textarea>
                            <div class="error-block">This field is required</div>
                        </div>
                    </div>
                    <div class="form-group">
                        <label class="col-xs-4 control-label">Medical History:</label>
                        <div class="col-xs-8">
                            <textarea class="form-control" name="medicalHistory"><%= referral.medicalHistory %></textarea>
                            <div class="error-block">This field is required</div>
                        </div>
                    </div>
                    <br />
                    <div>
                    <% if (referral.complete) { %>
                    <div class="referral-stamp"></div>
                    <% }%>
                    <% if (!referral.complete) { %>
                    <button type="submit" class="btn btn-info btn-refer pull-right">Refer</button>
                    <% }%>
                    </div>
                    <div class="clearfix"></div>
                </form>
            </div>
        </div>
    </div>
</div>