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Layout XML editor - Layout type: schPatient.CheckIn

SchPatientRoot

Margins left Body Unconditional Section Demographic Group Patient Name Patient Name form Patient ID Patient ID form Demographic Group 2 PatientDOB PatientDOB form Patient sex Patient sex form Patient Minor Patient Minor form SSN SSN form Weight Weight form Heigth Heigth form Address/Phone Address Box Address Address form Address 2 Address 2 form City City form State State form ZIP ZIP form m Phone box Phone Number Phone Number form Phone Number (2) Phone Number (2) form Phone Number (3) Phone Number (3) form E-mail Address E-mail Address form HIPAA HIPAA form Alert Group Metal Implants Label Metal Implants History of Cancer Label History of Cancer History of Brain Tumor Label History of Brain Tumor Work with Metal Label Work with Metal Claustrophobic label Claustrophobic Diabetic Label Diabetic Multiple Myeloma Label Multiple Myeloma Problem with I.V. Label Problem with I.V. Implanted Pump Label Implanted Pump Tattoos Label Tattoos Gunshot Label Gunshot Injury to eye Label Injury to eye Surgeries Box Previous Surgeries Label Previous Surgeries Surgeries on what body part? Label Surgeries on what body part? Allergies Box Allergy to Latex Allergy to Latex form Allergy to Shellfish Allergy to Shellfish form Allergy to Iodine Allergy to Iodine form Allergy to Lidocaine Allergy to Lidocaine form Guardian Section Guardian Name Box Guardian Name Label Guardian Name Guard. Address/Phone Guard. Address Box Guardian Address Label Guardian Address Guardian Address 2 Label Guardian Address 2 Guardian City Label Guardian City Guardian ZIP Label Guardian ZIP Guardian State Label Guardian State m2 Guard. Phone Guardian Phone Label Guardian Phone Guardian Relationship Label Guardian Relationship Employer Info Employer Name Box Place of Employment Label Place of Employment Employer Contact Group Emp. Address Box Address of Employment Label Address of Employment Address 2 of Employment Label Address 2 of Employment City of Employment Label City of Employment State of Employment Label State of Employment Zip of Employment Label Zip of Employment m4 Emp. Phone Box Phone of Employment Label Phone of Employment Ext of Employment Label Ext of Employment Emergency contact Section Emergency contact Name Box Emergency contact Name Label Emergency contact Name Emergency contact Phone Label Emergency contact Phone Emergency contact Relationship Label Emergency contact Relationship Insurer Section Insurer Group Layout Insurer Body Insurer Name Box Insurance Provider Insurance Provider form Insurer Data Box Group Number Group Number form Policy Number Policy Number form Effective Date Effective Date form Termination Date Termination Date form Guarantor Group 1 Guarantor Name Guarantor Name form Guarantor Contact Group Guarantor Address Box Guarantor Address Label Guarantor Address Guarantor Address 2 Label Guarantor Address 2 Guarantor City Label Guarantor City Guarantor State Label Guarantor State Guarantor ZIP Label Guarantor ZIP m6 Guarantor Phone Box Guarantor Phone Label Guarantor Phone Guarantor Relationship Label Guarantor Relationship Guarantor DoB Label Guarantor DoB Delete Body Delete box Insurer Delete v7 Admin only Admin Box Deleted Deleted form Button Box ButtonTable saveconfirm button Save Button SaveAndCreateOrder Button Back Button Cancel Button right