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dumptruckman/dabblet.css

Created June 10, 2014 22:41
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dabblet.css
/**
* The first commented line is your dabblet’s title
*/
background: #f06;
background: linear-gradient(45deg, #f06, yellow);
min-height: 100%;
Raw
dabblet.html
<html>
<head>
<meta http-equiv="Content-Type" content="text/html; charset=ISO-8859-1">
</head>
<style>
</style>
<body>
<form action="">
<table style="border-collapse:collapse" border="1">
<tr>
<td colspan=3>Patient's Legal Name:<br><input style="width:99%" name="name" type="text" placeholder="Last, First, Middle"></td>
<td colspan=1>Nickname:<br><input style="width:99%" type="text"></td>
</tr>
<tr>
<td>Gender:<br><input name="gender" type="radio">Female <input name="gender" type="radio">Male</td>
<td>Date of Birth:<br><input style="width:98%" type="text" placeholder="00/00/0000"></td>
<td>Social Security Number:<br><input style="width:98%" type="text" placeholder="000-00-0000"></td>
<td>Preferred Language:<br><input style="width:98%" name="language" type="text"></td>
</tr>
<tr>
<td colspan=2>Race:
<table>
<tr>
<td valign="top"><input name="race" type="checkbox">American Indian or Alaska Native</td>
<td valign="top"><input name="race" type="checkbox">Asian</td>
<td valign="top"><input name="race" type="checkbox">Black or African American</td>
</tr>
<tr>
<td valign="top"><input name="race" type="checkbox">Native Hawaiian or Other Pacific Islander</td>
<td valign="top"><input name="race" type="checkbox">White</td>
<td valign="top"><input name="race" type="checkbox">Decline to specify</td>
</tr>
</table>
</td>
<td colspan=2>Ethnicity:<br>
<input name="ethnicity" type="radio">Hispanic or Latino<br>
<input name="ethnicity" type="radio">Not Hispanic or Latino<br>
<input name="ethnicity" type="radio">Decline to specify
</td>
</tr>
<tr>
<td colspan=4>
Patient Address
<table style="width:100%">
<tr>
<td style="width:50%">Street:<br><input style="width:99%" type="text" placeholder="required"></td>
<td>City:<br><input style="width:99%" type="text"></td>
<td>State:<br><input style="width:99%" type="text"></td>
<td>Zip Code:<br><input style="width:99%" type="text"></td>
</tr>
</table>
</td>
</tr>
<tr>
<td>Home Phone Number (may be same as cell):<br><input type="text" placeholder="required"></td>
<td>Cell Phone Number<br><input type="text"></td>
<td>Work Phone Number<br><input type="text"></td>
</tr>
<tr>
<td>Email Address<br><input name="email" type="text"></td>
<td>Can we email you regarding<br>appointments?<input name="email-appt-remind" type="radio">Y<input name="email-appt-remind" type="radio">N</td>
</tr>
<tr>
<td>Who referred you to this office?<br><input type="text"></td>
<td>Do you have any family members in this office?<br><input type="text"></td>
<td>What is your reason for coming to this office?<br><input type="text"></td>
</tr>
<tr>
<td>EMERGENCY CONTACT INFORMATION</td>
</tr>
<tr>
<td>Name<br><input type="text" placeholder="Last, First, Middle "></td>
<td>Contact Phone Number:<input type="radio">Home<input type="radio">Cell<br><input type="text"></td>
</tr>
<tr>
<td>Street Address<br><input type="text" placeholder="required"></td>
<td>City<br><input type="text"></td>
<td>State<br><input type="text"></td>
</tr>
<tr>
<td>Contact Relationship To Patient:<input type="radio">Child<input type="radio">Spouse<br><input type="radio">Other___________<br></td>
<td>Contact's Work Phone<br><input type="text"></td>
</tr>
<tr>
<td>Please continue form on back <br>and note all sections MUST BE COMPLETED</td>
</tr>
<tr>
<td>PRIMARY INSURANCE <br>HOLDER/PERSON RESPONSIBLE FOR BILL:<br><input type="text"><br><input type="radio">Check Here if Same As Patient</td>
</tr>
<tr>
<td>Legal Name:<br><input type="text" placeholder="Last, First, Middle "></td>
<td>Social Security Number:<br><input type="text" placeholder="000-00-0000"></td>
</tr>
<tr>
<td>Street Address<br><input type="text" placeholder="required"></td>
<td>P.O.Box<br><input type="text"></td>
<td>P.O.Box Zip Code<br><input type="text"></td>
</tr>
<tr>
<td>City<br><input type="text"></td>
<td>State<br><input type="text"></td>
<td>Zip Code<br><input type="text"></td>
<td>Contact Phone Number:<input type="radio">Home<input type="radio">Cell<br><input type="text"></td>
</tr>
<tr>
<td>Date of Birth<br><input type="text" placeholder="00/00/0000"></td>
<td>Gender:<br><input type="radio">Female<input type="radio">Male</td>
<td>Relationship To Patient:<input type="radio">Self<input type="radio">Spouse<input type="radio">Child<br><input type="radio">Other___________<br></td>
</tr>
<tr>
<td>INSURANCE INFORMATION</td>
</tr>
<tr>
<td>Name of Primary Insurance</td>
<td>Name of Secondary Insurance</td>
</tr>
</table>
</form>
</body>
</html>
Raw
dabblet.js
// alert('Hello world!');
Raw
settings.json
{"view":"split","fontsize":"100","seethrough":"","prefixfree":"1","page":"html"}
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