Skip to content

Instantly share code, notes, and snippets.

@icecreamsandwich

icecreamsandwich/miscModel_misc.js

Last active December 16, 2019 07:32
Show Gist options
  • Save icecreamsandwich/8a73cf61f4d6c34fbba58954ae708111 to your computer and use it in GitHub Desktop.
Save icecreamsandwich/8a73cf61f4d6c34fbba58954ae708111 to your computer and use it in GitHub Desktop.
Download ZIP
Raw
miscModel_misc.js
const fs = require('fs');
var pdf = require('html-pdf');
var nodemailer = require('nodemailer');
var transporter = nodemailer.createTransport({
service: 'gmail',
auth: {
user: 'muneebkt@gmail.com',
pass: ''
}
});
module.exports = {
convertHtmlToPdf,
uploadCanvasImage
};
async function convertHtmlToPdf(image_ar) {
if(image_ar.length > 0){
var image1 = `http://192.168.5.16/eventorg_analytics/signatures/${image_ar[0]}`;
var image2 = `http://192.168.5.16/eventorg_analytics/signatures/${image_ar[1]}`;
var image3 = `http://192.168.5.16/eventorg_analytics/signatures/${image_ar[2]}`;
var image4 = `http://192.168.5.16/eventorg_analytics/signatures/${image_ar[3]}`;
var image5 = `http://192.168.5.16/eventorg_analytics/signatures/${image_ar[4]}`;
}
var html = `<html>
<head>
<title>Cytec PDF</title>
<style>
table {
font-family: arial, sans-serif;
border-collapse: collapse;
width: 100%;
margin-top: 50px;
font-size: 10px;
}
td,
th {
border: .2px solid #edf4ff;
/* border-bottom: none; */
text-align: left;
padding: 10px;
}
tr{
height: 40px;
}
tr:nth-child(even) {
background-color: #edf4ff;
}
h3 {
background-color: #5778b1;
color: white;
border: .2px solid #5778b1;
}
h4 {
margin-top: 5px;
margin-bottom: 5px;
}
#header {
border: none !important;
margin-top: 0px;
}
</style>
</head>
<body>
<table id="header">
<tr>
<th id="header" colspan="4">
<img src="./assets/yteklogo.png" alt="logo" width="100px">
</th>
<th style="text-align: right;" id="header" colspan="2">
<span id="date"></span>
<script>
n = new Date();
y = n.getFullYear();
m = n.getMonth() + 1;
d = n.getDate();
document.getElementById("date").innerHTML = m + "/" + d + "/" + y;
</script>
</th>
</tr>
</table>
<table style="margin-top:0px;">
<tr>
<th colspan="6" style="background-color: #5778b1;color:white">
<h3>Demographic Information</h3>
</th>
</tr>
<tr>
<th colspan="6" style="background-color: #c9ddfc;">
<h4>Patient information</h4>
</th>
</tr>
<tr>
<th colspan="3"><b>Prefix</b></th>
<th colspan="3"><b>Sex</b></th>
</tr>
<tr>
<td colspan="3" style="width: 50%;"></td>
<td colspan="3"></td>
</tr>
<tr>
<td colspan="2"><b>First Name</b></td>
<td colspan="2"><b>Middle Name</b></td>
<td colspan="2"><b>Last Name</b></td>
</tr>
<tr>
<td colspan="2" id="patientfirstname" name="patientfirstname"></td>
<td colspan="2" id="patientmiddlename" name="patientmiddlename"></td>
<td colspan="2" id="patientlastname" name="patientlastname"></td>
</tr>
<tr>
<td colspan="2"><b>DOB</b></td>
<td colspan="2"><b>Age</b></td>
<td colspan="2"><b>Social Security Number</b></td>
</tr>
<tr>
<td colspan="2" id="datepicker" nmae="datepicker"></td>
<td colspan="2" id="age" nmae="age"></td>
<td colspan="2" id="socialsecuritynumber" name="socialsecuritynumber"></td>
</tr>
<tr>
<td colspan="6"><b>Email Address</b></td>
</tr>
<tr>
<td colspan="6" id="email" name="email"></td>
</tr>
<tr>
<td colspan="6"><b>Mailing Street Address</b></td>
</tr>
<tr>
<td colspan="6" id="streetaddress" name="streetaddress"></td>
</tr>
<tr>
<td colspan="3"><b>Apt.</b></td>
<td colspan="3"><b>City</b></td>
</tr>
<tr>
<td colspan="3" id="apt" name="apt"></td>
<td colspan="3" id="city" name="city"></td>
</tr>
<tr>
<td colspan="3"><b>State</b></td>
<td colspan="3"><b>Zip</b></td>
</tr>
<tr>
<td colspan="3" id="state" name="state"></td>
<td colspan="3" id="zip" name="zip"></td>
</tr>
<tr>
<td colspan="3"><b>Home Phone</b></td>
<td colspan="3"><b>Mobile Phone</b></td>
</tr>
<tr>
<td colspan="3" id="homephone" name="homephone"></td>
<td colspan="3" id="mobilenumber" name="mobilenumber"></td>
</tr>
<tr>
<td colspan="4"><b>Have you ever been a patient of our practice?</b></td>
<td colspan="2"></td>
</tr>
<tr>
<td colspan="4"><b>Has a family member ever been a patient of our practice?</b></td>
<td colspan="2"></td>
</tr>
<tr>
<td colspan="6"><b>Who were you referred by?</b></td>
</tr>
<tr>
<td colspan="3"><b>First Name</b></td>
<td colspan="3"><b>Last Name</b></td>
</tr>
<tr>
<td colspan="3"></td>
<td colspan="3"></td>
</tr>
<tr>
<td colspan="3"><b>Dentist First Name</b></td>
<td colspan="3"><b>Last Name</b></td>
</tr>
<tr>
<td colspan="3" id="dentistfirstname" name="dentistfirstname"></td>
<td colspan="3" id="dentistlastname" name="dentistlastname"></td>
</tr>
<tr>
<td colspan="3"><b>Orthodontist First Name</b></td>
<td colspan="3"><b>Last Name</b></td>
</tr>
<tr>
<td colspan="3" id="orthodontisfirstname" name="orthodontisfirstname"></td>
<td colspan="3" id="orthodontislastname" name="orthodontislastname"></td>
</tr>
<tr>
<td colspan="3"><b>Medical Doctor First Name</b></td>
<td colspan="3"><b>Last Name</b></td>
</tr>
<tr>
<td colspan="3" id="medicaldoctorfirstname" name="medicaldoctorfirstname"></td>
<td colspan="3" id="medicaldoctorlastname" name="medicaldoctorlastname"></td>
</tr>
<tr>
<td colspan="3"><b>Preferred Pharmacy Name</b></td>
<td colspan="3"><b>Preferred Pharmacy Phone</b></td>
</tr>
<tr>
<td colspan="3" id="preferredpharmacyname" name="preferredpharmacyname"></td>
<td colspan="3" id="preferredpharmacyphone" name="preferredpharmacyphone"></td>
</tr>
<tr>
<td colspan="6" style="background-color: #c9ddfc;">
<h4>Section Two</h4>
</td>
</tr>
<tr>
<td colspan="6"><b>Driver's License Number</b></td>
</tr>
<tr>
<td colspan="6" id="licensenumber" name="licensenumber"></td>
</tr>
<tr>
<td colspan="3"><b>Nearest relative not living with you :First Name </b></td>
<td colspan="3"><b>Last Name</b></td>
</tr>
<tr>
<td colspan="3" id="relativefirstname" name="relativefirstname"></td>
<td colspan="3" id="relativelastname" name="relativelastname"></td>
</tr>
<tr>
<td colspan="6"><b>Relative Phone</b></td>
</tr>
<tr>
<td colspan="6" id="relativefirstname" name="relativefirstname"></td>
</tr>
<tr>
<td colspan="6"><b>Employer/Business Name</b></td>
</tr>
<tr>
<td colspan="6" id="employername" name="employername"></td>
</tr>
<tr>
<td colspan="6"><b>Business Phone</b></td>
</tr>
<tr>
<td colspan="6" id="businessphone" name="businessphone"></td>
</tr>
<tr>
<td colspan="4"><b>Personal Payment Type</b></td>
<td colspan="2" id="personalpaymenttype" name="personalpaymenttype"></td>
</tr>
<tr>
<td colspan="4"><b>Who will be responsible for your account?</b></td>
<td colspan="2" id="responsibleforyouraccount" name="responsibleforyouraccount"></td>
</tr>
<tr style="background-color: #c9ddfc;">
<td colspan="6">
<h4>Who will be responsible for your account</h4>
</td>
</tr>
<tr>
<td colspan="3"><b>First Name</b></td>
<td colspan="3"><b>Last Name</b></td>
</tr>
<tr>
<td colspan="3" id="responsiblefirstname" name="responsiblefirstname"></td>
<td colspan="3" id="responsiblelastname" name="responsiblelastname"></td>
</tr>
<tr>
<td colspan="6"><b>Social Security Number</b></td>
</tr>
<tr>
<td colspan="6" id="responsiblesocialsecuritynumber"></td>
</tr>
<tr>
<td colspan="3"><b>Birth Date</b></td>
<td colspan="3"><b>Age</b></td>
</tr>
<tr>
<td colspan="3" id="responsiblebirthdate" name="responsiblebirthdate"></td>
<td colspan="3" id="responsibleage" name="responsibleage"></td>
</tr>
<tr>
<td colspan="3"><b>Responsible Party Home Phone</b></td>
<td colspan="3"><b>Responsible Party Mobile Number</b></td>
</tr>
<tr>
<td colspan="3" id="responsiblepartyhomephone" name="responsiblepartyhomephone"></td>
<td colspan="3" id="responsiblepartymobilenumber" name="responsiblepartymobilenumber"></td>
</tr>
<tr>
<td colspan="3"><b>Email</b></td>
<td colspan="3"><b>Driver's License Number</b></td>
</tr>
<tr>
<td colspan="3" id="responsibleemail" name="responsibleemail"></td>
<td colspan="3" id="responsibledriverslicensenumber" name="responsibledriverslicensenumber"></td>
</tr>
<tr>
<td colspan="6"><b>Street Address</b></td>
</tr>
<tr>
<td colspan="6" id="responsiblestreetaddress" name="responsiblestreetaddress"></td>
</tr>
<tr>
<td colspan="3"><b>Apt.</b></td>
<td colspan="3"><b>City</b></td>
</tr>
<tr>
<td colspan="3" id="responsibleapt" name="responsibleapt"></td>
<td colspan="3" id="responsiblecity" name="responsiblecity"></td>
</tr>
<tr>
<td colspan="3"><b>State</b></td>
<td colspan="3"><b>Zip(Postal Code)</b></td>
</tr>
<tr>
<td colspan="3" id="responsiblestate" name="responsiblestate"></td>
<td colspan="3" id="responsiblezip" name="responsiblezip"></td>
</tr>
<tr>
<td colspan="3"><b>Employer/Business Name</b></td>
<td colspan="3"><b>Business Phone</b></td>
</tr>
<tr>
<td colspan="3" id="responsibleemployername" name="responsibleemployername"></td>
<td colspan="3" id="responsiblebusinessphone" name="responsiblebusinessphone"></td>
</tr>
<tr style="background-color: #c9ddfc;">
<td colspan="6">
<h4>Spouse or other guarantor information (if different from above)</h4>
</td>
</tr>
<tr>
<td colspan="3"><b>First name</b></td>
<td colspan="3"><b>Last Name</b></td>
</tr>
<tr>
<td colspan="3" id="otherfirstname" name="otherfirstname"></td>
<td colspan="3" id="otherlastname" name="otherlastname"></td>
</tr>
<tr>
<td colspan="6"><b>Relation</b></td>
</tr>
<tr>
<td colspan="6" id="otherrelation" name="otherrelation"></td>
</tr>
<tr>
<td colspan="3"><b>Birth Date</b></td>
<td colspan="3"><b>Social Security Number</b></td>
</tr>
<tr>
<td colspan="3" id="otherbirthdate" name="otherbirthdate"></td>
<td colspan="3" id="othersocialsecuritynumber" name="othersocialsecuritynumber"></td>
</tr>
<tr>
<td colspan="6"><b>Home Phone</b></td>
</tr>
<tr>
<td colspan="6" id="otherhomephone" name="otherhomephone"></td>
</tr>
<tr>
<td colspan="6"><b>Street Address</b></td>
</tr>
<tr>
<td colspan="6" id="otherstreetaddress" name="otherstreetaddress"></td>
</tr>
<tr>
<td colspan="3"><b>Apt.</b></td>
<td colspan="3"><b>City</b></td>
</tr>
<tr>
<td colspan="3" id="otherapt" name="otherapt"></td>
<td colspan="3" id="othercity" name="othercity"></td>
</tr>
<tr>
<td colspan="3"><b>State</b></td>
<td colspan="3"><b>Zip(Postal Code</b></td>
</tr>
<tr>
<td colspan="3" id="otherstate" name="otherstate"></td>
<td colspan="3" id="otherzip" name="otherzip"></td>
</tr>
<tr>
<td colspan="3"><b>Employer/Business Name</b></td>
<td colspan="3"><b>Business Phone</b></td>
</tr>
<tr>
<td colspan="3" id="otheremployername" name="otheremployername"></td>
<td colspan="3" id="otherbusinessphone" name="otherbusinessphone"></td>
</tr>
</table>
<table>
<tr style="background-color: #5778b1;color:white">
<th colspan="6">
<h3>Insurance Information</h3>
</th>
</tr>
<tr style="background-color: #c9ddfc;">
<td colspan="6">
<h4>General Insurance Information</h4>
</td>
</tr>
<tr>
<td colspan="4" style="width: 66.66%;"><b>Employed</b></td>
<td colspan="2" id="generalinsuranceinformationemployed" name="generalinsuranceinformationemployed"></td>
</tr>
<tr>
<td colspan="4"><b>Do you belong to a PPO or HMO?</b></td>
<td colspan="2" id="generalinsuranceinformationppo" name="generalinsuranceinformationppo"></td>
</tr>
<tr>
<td colspan="4"><b>Marital status</b></td>
<td colspan="2" id="generalinsuranceinformationmaritalstatus"
name="generalinsuranceinformationmaritalstatus"></td>
</tr>
<tr>
<td colspan="4"><b>Are you a student?</b></td>
<td colspan="2" id="student" name="student"></td>
</tr>
<tr style="background-color: #c9ddfc;">
<td colspan="6">
<h4> School Information</h4>
</td>
</tr>
<tr>
<td colspan="6"><b>School Name</b></td>
</tr>
<tr>
<td colspan="6" id="studentschoolname" name="studentschoolname"></td>
</tr>
<tr>
<td colspan="6"><b>School Street Address</b></td>
</tr>
<tr>
<td colspan="6" id="studentschoolstreetaddress" name="studentschoolstreetaddress"></td>
</tr>
<tr>
<td colspan="3" style="width: 50%;"><b>City</b></td>
<td colspan="3"><b>State</b></td>
</tr>
<tr>
<td colspan="3" id="studentschoolcity" name="studentschoolcity"></td>
<td colspan="3" id="studentschoolstate" name="studentschoolstate"></td>
</tr>
<tr>
<td colspan="6"><b>Zip(Postal Code)</b></td>
</tr>
<tr>
<td colspan="6" id="studentschoolzip" name="studentschoolzip"></td>
</tr>
<tr style="background-color: #c9ddfc;">
<td colspan="6">
<h4> Primary Dental Insurance Information</h4>
</td>
</tr>
<tr>
<td colspan="6"><b>Employer / Business Name</b></td>
</tr>
<tr>
<td colspan="6" id="primarydentalemployername" name="primarydentalemployername"></td>
</tr>
<tr>
<td colspan="6"><b>Business Street Address</b></td>
</tr>
<tr>
<td colspan="6" id="primarydentalstreetaddress" name="primarydentalstreetaddress"></td>
</tr>
<tr>
<td colspan="3"><b>City</b></td>
<td colspan="3"><b>State</b></td>
</tr>
<tr>
<td colspan="3" id="primarydentalcity" name="primarydentalcity"></td>
<td colspan="3" id="primarydentalstate" name="primarydentalstate"></td>
</tr>
<tr>
<td colspan="6"><b>Zip(Postal Code)</b></td>
</tr>
<tr>
<td colspan="6" id="primarydentalzip" name="primarydenatlzip"></td>
</tr>
<tr>
<td colspan="6"><b>Business Phone Number</b></td>
</tr>
<tr>
<td colspan="6" id="primarydentalphonenumber" name="primarydentalphonenumber"></td>
</tr>
<tr>
<td colspan="6"><b>Plan Number</b></td>
</tr>
<tr>
<td colspan="6" id="primarydentalplannumber" name="primarydentalplannumber"></td>
</tr>
<tr>
<td colspan="6"><b>Policy I.D. Number</b></td>
</tr>
<tr>
<td colspan="6" id="primarydentalpolicyid" name="primarydentalpolicyid"></td>
</tr>
<tr>
<td colspan="6"><b>Insurence Company Address</b></td>
</tr>
<tr>
<td colspan="6" id="primarydentalinsurencecompanyaddress" name="primarydentalinsurencecompanyaddress"></td>
</tr>
<tr>
<td colspan="3"><b>City</b></td>
<td colspan="3"><b>State</b></td>
</tr>
<tr>
<td colspan="3" id="primarydentalinsurencecity" name="primarydentalinsurencecity"></td>
<td colspan="3" id="primarydentalinsurencestate" name="primarydentalinsurencestate"></td>
</tr>
<tr>
<td colspan="6"><b>Zip(Postal Code)</b></td>
</tr>
<tr>
<td colspan="6" id="primarydentalinsurencezip" name="primarydentalinsurencezip"></td>
</tr>
<tr>
<td colspan="6"><b>Phone Number</b></td>
</tr>
<tr>
<td colspan="6" id="primarydentalinsurencephonenumber" name="primarydentalinsurencephonenumber"></td>
</tr>
<tr>
<td colspan="3"><b>Group Name</b></td>
<td colspan="3"><b>Group Number</b></td>
</tr>
<tr>
<td colspan="3" id="primarydentalgroupname" name="primarydentalgroupname"></td>
<td colspan="3" id="primarydentalgroupnumber" name="primarydentalgroupnumber"></td>
</tr>
<tr>
<td colspan="3"><b>Insured Party First Name</b></td>
<td colspan="3"><b>Insured Party Last name</b></td>
</tr>
<tr>
<td colspan="3" id="primarydentalinsuredpartyfirstname" name="primarydentalinsuredpartyfirstname"></td>
<td colspan="3" id="primarydentalinsuredpartylastname" name="primarydentalinsuredpartylastname"></td>
</tr>
<tr>
<td colspan="3"><b>Relation</b></td>
<td colspan="3"><b>Birth Date</b></td>
</tr>
<tr>
<td colspan="3" id="primarydentalrealtion" name="primarydentalrealtion"></td>
<td colspan="3"></td>
</tr>
<tr>
<td colspan="4"><b>Insured Party Sex</b></td>
<td colspan="2" id="primarydentalinsuredpartysex" name="primarydentalinsuredpartysex"></td>
</tr>
<tr>
<td colspan="3"><b>Insured Party Phone</b></td>
<td colspan="3"><b>Social Security Number</b></td>
</tr>
<tr>
<td colspan="3" id="primarydentalinsuredpartyphone" name="primarydentalinsuredpartyphone"></td>
<td colspan="3" id="primarydentalsocialsecuritynumber" name="primarydentalsocialsecuritynumber"></td>
</tr>
<tr>
<td colspan="6"><b>Insured Party Street Address</b></td>
</tr>
<tr>
<td colspan="3"><b>City</b></td>
<td colspan="3"><b>State</b></td>
</tr>
<tr>
<td colspan="3" id="primarydentalinsuredpartycity" name="primarydentalinsuredpartycity"></td>
<td colspan="3" id="primarydentalinsuredpartystate" name="primarydentalinsuredpartystate"></td>
</tr>
<tr>
<td colspan="6"><b>Zip(Postal Code)</b></td>
</tr>
<tr>
<td colspan="6" id="primarydentalinsuredpartyzip" name="primarydentalinsuredpartyzip"></td>
</tr>
<tr style="background-color: #c9ddfc;">
<td colspan="6">
<h4> Primary Medical Insurance Information</h4>
</td>
</tr>
<tr>
<td colspan="6"><b>Employer / Business Name</b></td>
</tr>
<tr>
<td colspan="6" id="primarymedicalemployername" name="primarymedicalemployername"></td>
</tr>
<tr>
<td colspan="6"><b>Business Street Address</b></td>
</tr>
<tr>
<td colspan="6" id="primarymedicalstreetaddress" name="primarymedicalstreetaddress"></td>
</tr>
<tr>
<td colspan="3"><b>City</b></td>
<td colspan="3"><b>State</b></td>
</tr>
<tr>
<td colspan="3" id="primarymedicalcity" name="primarymedicalcity"></td>
<td colspan="3" id="primarymedicalstate" name="primarymedicalstate"></td>
</tr>
<tr>
<td colspan="6"><b>Zip(Postal Code)</b></td>
</tr>
<tr>
<td colspan="6" id="primarymedicalzip" name="primarymedicalzip"></td>
</tr>
<tr>
<td colspan="6"><b>Business Phone Number</b></td>
</tr>
<tr>
<td colspan="6" id="primarymedicalphonenumber" name="primarymedicalphonenumber"></td>
</tr>
<tr>
<td colspan="6"><b>Plan Number</b></td>
</tr>
<tr>
<td colspan="6" id="primarymedicalplannumber" name="primarymedicalplannumber"></td>
</tr>
<tr>
<td colspan="6"><b>Policy I.D. Number</b></td>
</tr>
<tr>
<td colspan="6" id="primarymedicalpolicyid" name="primarymedicalpolicyid"></td>
</tr>
<tr>
<td colspan="6"><b>Insurence Company Address</b></td>
</tr>
<tr>
<td colspan="6" id="primarymedicalinsurencecompanyaddress" name="primarymedicalinsurencecompanyaddress">
</td>
</tr>
<tr>
<td colspan="3"><b>City</b></td>
<td colspan="3"><b>State</b></td>
</tr>
<tr>
<td colspan="3" id="primarymedicalinsurencecity" name="primarymedicalinsurencecity"></td>
<td colspan="3" id="primarymedicalinsurencestate" name="primarymedicalinsurencestate"></td>
</tr>
<tr>
<td colspan="6"><b>Zip(Postal Code)</b></td>
</tr>
<tr>
<td colspan="6" id="primarymedicalinsurencezip" name="primarymedicalinsurencezip"></td>
</tr>
<tr>
<td colspan="6"><b>Phone Number</b></td>
</tr>
<tr>
<td colspan="6" id="primarymedicalinsurencephonenumber" name="primarymedicalinsurencephonenumber"></td>
</tr>
<tr>
<td colspan="3"><b>Group Name</b></td>
<td colspan="3"><b>Group Number</b></td>
</tr>
<tr>
<td colspan="3" id="primarymedicalgroupname" name="primarymedicalgroupname"></td>
<td colspan="3" id="primarymedicalgroupnumber" name="primarymedicalgroupnumber"></td>
</tr>
<tr>
<td colspan="3"><b>Insured Party First Name</b></td>
<td colspan="3"><b>Insured Party Last name</b></td>
</tr>
<tr>
<td colspan="3" id="primarymedicalinsuredpartyfirstname" name="primarymedicalinsuredpartyfirstname"></td>
<td colspan="3" id="primarymedicalinsuredpartylastname" name="primarymedicalinsuredpartylastname"></td>
</tr>
<tr>
<td colspan="3"><b>Relation</b></td>
<td colspan="3"><b>Birth Date</b></td>
</tr>
<tr>
<td colspan="3" id="primarymedicalrealtion" name="primarymedicalrealtion"></td>
<td colspan="3"></td>
</tr>
<tr>
<td colspan="4"><b>Insured Party Sex</b></td>
<td colspan="2" id="primarymedicalinsuredpartysex" name="primarymedicalinsuredpartysex"></td>
</tr>
<tr>
<td colspan="3"><b>Insured Party Phone</b></td>
<td colspan="3"><b>Social Security Number</b></td>
</tr>
<tr>
<td colspan="3" id="primarymedicalinsuredpartyphone" name="primarymedicalinsuredpartyphone"></td>
<td colspan="3" id="primarymedicalsocialsecuritynumber" name="primarymedicalsocialsecuritynumber"></td>
</tr>
<tr>
<td colspan="6"><b>Insured Party Street Address</b></td>
</tr>
<tr>
<td colspan="3"><b>City</b></td>
<td colspan="3"><b>State</b></td>
</tr>
<tr>
<td colspan="3" id="primarymedicalinsuredpartycity" name="primarymedicalinsuredpartycity"></td>
<td colspan="3" id="primarymedicalinsuredpartystate" name="primarymedicalinsuredpartystate"></td>
</tr>
<tr>
<td colspan="6"><b>Zip(Postal Code)</b></td>
</tr>
<tr>
<td colspan="6" id="primarymedicalinsuredpartyzip" name="primarymedicalinsuredpartyzip"></td>
</tr>
<tr>
<td colspan="4"><b>Do you have secondary dental or medical insurance?</b></td>
<td colspan="2"></td>
</tr>
<tr style="background-color: #c9ddfc;">
<td colspan="6">
<h4> Secondary Dental Insurance Information</h4>
</td>
</tr>
<tr>
<td colspan="6"><b>Employer / Business Name</b></td>
</tr>
<tr>
<td colspan="6" id="secondarydentalemployername" name="secondarydentalemployername"></td>
</tr>
<tr>
<td colspan="6"><b>Business Street Address</b></td>
</tr>
<tr>
<td colspan="6" id="secondarydentalstreetaddress" name="secondarydentalstreetaddress"></td>
</tr>
<tr>
<td colspan="3"><b>City</b></td>
<td colspan="3"><b>State</b></td>
</tr>
<tr>
<td colspan="3" id="secondarydentalcity" name="secondarydentalcity"></td>
<td colspan="3" id="secondarydentalstate" name="secondarydentalstate"></td>
</tr>
<tr>
<td colspan="6"><b>Zip(Postal Code)</b></td>
</tr>
<tr>
<td colspan="6" id="secondarydentalzip" name="secondarydenatlzip"></td>
</tr>
<tr>
<td colspan="6"><b>Business Phone Number</b></td>
</tr>
<tr>
<td colspan="6" id="secondarydentalphonenumber" name="secondarydentalphonenumber"></td>
</tr>
<tr>
<td colspan="6"><b>Plan Number</b></td>
</tr>
<tr>
<td colspan="6" id="secondarydentalplannumber" name="secondarydentalplannumber"></td>
</tr>
<tr>
<td colspan="6"><b>Policy I.D. Number</b></td>
</tr>
<tr>
<td colspan="6" id="secondarydentalpolicyid" name="secondarydentalpolicyid"></td>
</tr>
<tr>
<td colspan="6"><b>Insurence Company Address</b></td>
</tr>
<tr>
<td colspan="6" id="secondarydentalinsurencecompanyaddress" name="secondarydentalinsurencecompanyaddress">
</td>
</tr>
<tr>
<td colspan="3"><b>City</b></td>
<td colspan="3"><b>State</b></td>
</tr>
<tr>
<td colspan="3" id="secondarydentalinsurencecity" name="secondarydentalinsurencecity"></td>
<td colspan="3" id="secondarydentalinsurencestate" name="secondarydentalinsurencestate"></td>
</tr>
<tr>
<td colspan="6"><b>Zip(Postal Code)</b></td>
</tr>
<tr>
<td colspan="6" id="secondarydentalinsurencezip" name="secondarydentalinsurencezip"></td>
</tr>
<tr>
<td colspan="6"><b>Phone Number</b></td>
</tr>
<tr>
<td colspan="6" id="secondarydentalinsurencephonenumber" name="secondarydentalinsurencephonenumber"></td>
</tr>
<tr>
<td colspan="3"><b>Group Name</b></td>
<td colspan="3"><b>Group Number</b></td>
</tr>
<tr>
<td colspan="3" id="secondarydentalgroupname" name="secondarydentalgroupname"></td>
<td colspan="3" id="secondarydentalgroupnumber" name="secondarydentalgroupnumber"></td>
</tr>
<tr>
<td colspan="3"><b>Insured Party First Name</b></td>
<td colspan="3"><b>Insured Party Last name</b></td>
</tr>
<tr>
<td colspan="3" id="secondarydentalinsuredpartyfirstname" name="secondarydentalinsuredpartyfirstname"></td>
<td colspan="3" id="secondarydentalinsuredpartylastname" name="secondarydentalinsuredpartylastname"></td>
</tr>
<tr>
<td colspan="3"><b>Relation</b></td>
<td colspan="3"><b>Birth Date</b></td>
</tr>
<tr>
<td colspan="3" id="secondarydentalrealtion" name="secondarydentalrealtion"></td>
<td colspan="3"></td>
</tr>
<tr>
<td colspan="4"><b>Insured Party Sex</b></td>
<td colspan="2" id="secondarydentalinsuredpartysex" name="secondarydentalinsuredpartysex"></td>
</tr>
<tr>
<td colspan="3"><b>Insured Party Phone</b></td>
<td colspan="3"><b>Social Security Number</b></td>
</tr>
<tr>
<td colspan="3" id="secondarydentalinsuredpartyphone" name="secondarydentalinsuredpartyphone"></td>
<td colspan="3" id="secondarydentalsocialsecuritynumber" name="secondarydentalsocialsecuritynumber"></td>
</tr>
<tr>
<td colspan="6"><b>Insured Party Street Address</b></td>
</tr>
<tr>
<td colspan="3"><b>City</b></td>
<td colspan="3"><b>State</b></td>
</tr>
<tr>
<td colspan="3" id="secondarydentalinsuredpartycity" name="secondarydentalinsuredpartycity"></td>
<td colspan="3" id="secondarydentalinsuredpartystate" name="secondarydentalinsuredpartystate"></td>
</tr>
<tr>
<td colspan="6"><b>Zip(Postal Code)</b></td>
</tr>
<tr>
<td colspan="6" id="secondarydentalinsuredpartyzip" name="secondarydentalinsuredpartyzip"></td>
</tr>
<tr style="background-color: #c9ddfc;">
<td colspan="6">
<h4> Secondary Medical Insurance Information</h4>
</td>
</tr>
<tr>
<td colspan="6"><b>Employer / Business Name</b></td>
</tr>
<tr>
<td colspan="6" id="secondarymedicalemployername" name="secondarymedicalemployername"></td>
</tr>
<tr>
<td colspan="6"><b>Business Street Address</b></td>
</tr>
<tr>
<td colspan="6" id="secondarymedicalstreetaddress" name="secondarymedicalstreetaddress"></td>
</tr>
<tr>
<td colspan="3"><b>City</b></td>
<td colspan="3"><b>State</b></td>
</tr>
<tr>
<td colspan="3" id="secondarymedicalcity" name="secondarymedicalcity"></td>
<td colspan="3" id="secondarymedicalstate" name="secondarymedicalstate"></td>
</tr>
<tr>
<td colspan="6"><b>Zip(Postal Code)</b></td>
</tr>
<tr>
<td colspan="6" id="secondarymedicalzip" name="secondarymedicalzip"></td>
</tr>
<tr>
<td colspan="6"><b>Business Phone Number</b></td>
</tr>
<tr>
<td colspan="6" id="secondarymedicalphonenumber" name="secondarymedicalphonenumber"></td>
</tr>
<tr>
<td colspan="6"><b>Plan Number</b></td>
</tr>
<tr>
<td colspan="6" id="secondarymedicalplannumber" name="secondarymedicalplannumber"></td>
</tr>
<tr>
<td colspan="6"><b>Policy I.D. Number</b></td>
</tr>
<tr>
<td colspan="6" id="secondarymedicalpolicyid" name="secondarymedicalpolicyid"></td>
</tr>
<tr>
<td colspan="6"><b>Insurence Company Address</b></td>
</tr>
<tr>
<td colspan="6" id="secondarymedicalinsurencecompanyaddress" name="secondarymedicalinsurencecompanyaddress">
</td>
</tr>
<tr>
<td colspan="3"><b>City</b></td>
<td colspan="3"><b>State</b></td>
</tr>
<tr>
<td colspan="3" id="secondarymedicalinsurencecity" name="secondarymedicalinsurencecity"></td>
<td colspan="3" id="secondarymedicalinsurencestate" name="secondarymedicalinsurencestate"></td>
</tr>
<tr>
<td colspan="6"><b>Zip(Postal Code)</b></td>
</tr>
<tr>
<td colspan="6" id="secondarymedicalinsurencezip" name="secondarymedicalinsurencezip"></td>
</tr>
<tr>
<td colspan="6"><b>Phone Number</b></td>
</tr>
<tr>
<td colspan="6" id="secondarymedicalinsurencephonenumber" name="secondarymedicalinsurencephonenumber"></td>
</tr>
<tr>
<td colspan="3"><b>Group Name</b></td>
<td colspan="3"><b>Group Number</b></td>
</tr>
<tr>
<td colspan="3" id="secondarymedicalgroupname" name="secondarymedicalgroupname"></td>
<td colspan="3" id="secondarymedicalgroupnumber" name="secondarymedicalgroupnumber"></td>
</tr>
<tr>
<td colspan="3"><b>Insured Party First Name</b></td>
<td colspan="3"><b>Insured Party Last name</b></td>
</tr>
<tr>
<td colspan="3" id="secondarymedicalinsuredpartyfirstname" name="secondarymedicalinsuredpartyfirstname">
</td>
<td colspan="3" id="secondarymedicalinsuredpartylastname" name="secondarymedicalinsuredpartylastname"></td>
</tr>
<tr>
<td colspan="3"><b>Relation</b></td>
<td colspan="3"><b>Birth Date</b></td>
</tr>
<tr>
<td colspan="3" id="secondarymedicalrealtion" name="secondarymedicalrealtion"></td>
<td colspan="3"></td>
</tr>
<tr>
<td colspan="4"><b>Insured Party Sex</b></td>
<td colspan="2" id="secondarymedicalinsuredpartysex" name="secondarymedicalinsuredpartysex"></td>
</tr>
<tr>
<td colspan="3"><b>Insured Party Phone</b></td>
<td colspan="3"><b>Social Security Number</b></td>
</tr>
<tr>
<td colspan="3" id="secondarymedicalinsuredpartyphone" name="secondarymedicalinsuredpartyphone"></td>
<td colspan="3" id="secondarymedicalsocialsecuritynumber" name="secondarymedicalsocialsecuritynumber"></td>
</tr>
<tr>
<td colspan="6"><b>Insured Party Street Address</b></td>
</tr>
<tr>
<td colspan="3"><b>City</b></td>
<td colspan="3"><b>State</b></td>
</tr>
<tr>
<td colspan="3" id="secondarymedicalinsuredpartycity" name="secondarymedicalinsuredpartycity"></td>
<td colspan="3" id="secondarymedicalinsuredpartystate" name="secondarymedicalinsuredpartystate"></td>
</tr>
<tr>
<td colspan="6"><b>Zip(Postal Code)</b></td>
</tr>
<tr>
<td colspan="6" id="secondarymedicalinsuredpartyzip" name="secondarymedicalinsuredpartyzip"></td>
</tr>
<tr>
<td colspan="4"><b>Do you have secondary dental or medical insurance?</b></td>
<td colspan="2"></td>
</tr>
</table>
<table>
<tr style="background-color: #5778b1;color:white">
<td colspan="6">
<h3>Health History</h3>
</td>
</tr>
<tr style="background-color: #c9ddfc;">
<td colspan="6">
<h4>Health History</h4>
</td>
</tr>
<tr>
<td colspan="6"><b>To our patients:</b> Although oral surgeons primarily treat the area in and around your
mouth,
your mouth is a part of your entire body. Health problems that you may have or medication that you may
be taking, could have an important interrelationship with the care that you will be receiving. Thank you
for answering the following questions. Your answers are for our records only and will be considered
confidential.</td>
</tr>
<tr>
<td colspan="6"><b>What is your reason for visiting our practice?</b></td>
</tr>
<tr>
<td colspan="6" id="healthhistorypractice" name="healthhistorypractice"></td>
</tr>
<tr>
<td colspan="3" style="width: 50%;"><b>What is your height?</b></td>
<td colspan="3"><b>What is your weight?</b></td>
</tr>
<tr>
<td colspan="3" id="healthhistoryheight" name="healthhistoryheight"></td>
<td colspan="3" id="healthhistoryweight" name="healthhistoryweight"></td>
</tr>
<tr>
<td colspan="4"><b>Are you in good health?</b></td>
<td colspan="2" id="healthhistorygood" name="healthhistorygood"></td>
</tr>
<tr>
<td colspan="4" style="width: 66.66%;"><b>Have there been any changes in your general health in the past
year?</b></td>
<td colspan="2" id="healthhistorypastyear" name="healthhistorypastyear"></td>
</tr>
<tr>
<td colspan="4"><b>Are you under the care of a physician?</b></td>
<td colspan="2" id="healthhistoryphysician" name="healthhistoryphysician"></td>
</tr>
<tr>
<td colspan="4"><b>If so,What are you being treated for?</b></td>
<td colspan="2" id="healthhistorytreated" name="healthhistorytreated"></td>
</tr>
<tr>
<td colspan="4"><b>Date of last visit</b></td>
<td colspan="2" id="healthhistorylastvisit" name="healthhistorylastvisit"></td>
</tr>
<tr>
<td colspan="4"><b>Have you had any illness, operation or been hospitalized in the past five years?</b></td>
<td colspan="2" id="healthhistoryfiveyears" name="healthhistoryfiveyears"></td>
</tr>
<tr>
<td colspan="6"><b>If so,Describe</b></td>
</tr>
<tr>
<td colspan="6" id="healthhistorydescribe" name="healthhistorydescribe"></td>
</tr>
<tr>
<td colspan="4"><b>Do you have unhealed/recurrent injuries or inflamed areas, growths or sore spots in or
around your mouth?</b></td>
<td colspan="2" id="healthhistorymouth" name="healthhistorymouth"></td>
</tr>
<tr>
<td colspan="6"><b>If so,Describe</b></td>
</tr>
<tr>
<td colspan="6" id="healthhistorymouthdescribe" name="healthhistorymouthdescribe"></td>
</tr>
<tr>
<td colspan="4"><b>Do you have a prosthetic joint/implant?</b></td>
<td colspan="2" id="healthhistoryimplant" name="healthhistoryimplant"></td>
</tr>
<tr>
<td colspan="6"><b>If so,Describe</b></td>
</tr>
<tr>
<td colspan="6" id="healthhistoryimplantdescribe" name="healthhistoryimplantdescribe"></td>
</tr>
<tr>
<td colspan="4"><b>Have you had a heart valve replacement or vascular graft?</b></td>
<td colspan="2" id="healthhistoryvasculargraftdescribe" name="healthhistoryvasculargraftdescribe"></td>
</tr>
<tr>
<td colspan="4"><b>Have you ever had general anesthesia?</b></td>
<td colspan="2" id="healthhistorygeneralanesthesia" name="healthhistorygeneralanesthesia"></td>
</tr>
<tr>
<td colspan="4"><b>Have you, or a family member, had any unusual or serious reactions to general
anesthesia?</b></td>
<td colspan="2" id="healthhistoryseriousreactionsto" name="healthhistoryseriousreactionsto"></td>
</tr>
<tr>
<td colspan="4"><b>Has a physician or previous dentist recommended that you take antibiotics prior to your
dental treatment?</b></td>
<td colspan="2" id="healthhistorydentaltreatment" name="healthhistorydentaltreatment"></td>
</tr>
<tr>
<td colspan="4"><b>Is there any condition concerning your health that the doctor should be told about?</b>
</td>
<td colspan="2" id="healthhistorytoldabout" name="healthhistorytoldabout"></td>
</tr>
<tr>
<td colspan="6"><b>If so,Describe</b></td>
</tr>
<tr>
<td colspan="6" id="healthhistorytoldaboutdescribe" name="healthhistorytoldaboutdescribe"></td>
</tr>
<tr>
<td colspan="4"><b>Do you wish to speak to the doctor privately about anything?</b></td>
<td colspan="2" id="healthhistoryprivatelyaboutanything" name="healthhistoryprivatelyaboutanything"></td>
</tr>
<tr>
<td colspan="4"><b>If you are having surgery today, have you had anything to eat or drink in the last 6
(six) hours?</b></td>
<td colspan="2" id="healthhistoryprivatelyaboutanything" name="healthhistoryprivatelyaboutanything"></td>
</tr>
<tr>
<td colspan="6"><b>Who is driving you home?</b></td>
</tr>
<tr>
<td colspan="6" id="healthhistorydrivingyouhome" name="healthhistorydrivingyouhome"></td>
</tr>
</table>
<table>
<tr style="background-color: #5778b1;color:white">
<td colspan="6">
<h3>Health History Part 2</h3>
</td>
</tr>
<tr style="background-color: #c9ddfc;">
<td colspan="6">
<h4>Have you had or do you currently have...</h4>
</td>
</tr>
<tr>
<td colspan="4" style="width: 66.66%;"><b>Rheumatic fever</b>
</td>
<td colspan="2" id="healthhistory2rheumaticever" name="healthhistory2rheumaticever"></td>
</tr>
<tr>
<td colspan="4"><b>Damaged heart valves / mitral valve prolapse</b>
</td>
<td colspan="2" id="healthhistory2damagedheartvalves" name="healthhistory2damagedheartvalves"></td>
</tr>
<tr>
<td colspan="4"><b>Heart murmur</b>
</td>
<td colspan="2" id="healthhistory2heartmurmur" name="healthhistory2heartmurmur"></td>
</tr>
<tr>
<td colspan="4"><b>High blood pressure</b>
</td>
<td colspan="2" id="healthhistory2highbloodpressure" name="healthhistory2highbloodpressure"></td>
</tr>
<tr>
<td colspan="4"><b>Low blood pressure</b>
</td>
<td colspan="2" id="healthhistory2lowbloodpressure" name="healthhistory2lowbloodpressure"></td>
</tr>
<tr>
<td colspan="4"><b>Chest pain / angina</b>
</td>
<td colspan="2" id="healthhistory2chestpain" name="healthhistory2chestpain"></td>
</tr>
<tr>
<td colspan="4"><b>Heart attack(s)</b>
</td>
<td colspan="2" id="healthhistory2heartattack" name="healthhistory2heartattack"></td>
</tr>
<tr>
<td colspan="4"><b>Irregular heart beat</b>
</td>
<td colspan="2" id="healthhistory2irregularheartbeat" name="healthhistory2irregularheartbeat"></td>
</tr>
<tr>
<td colspan="4"><b>Cardiac pacemaker</b>
</td>
<td colspan="2" id="healthhistory2cardiacpacemaker" name="healthhistory2cardiacpacemaker"></td>
</tr>
<tr>
<td colspan="4"><b>Heart surgery</b>
</td>
<td colspan="2" id="healthhistory2heartsurgery" name="healthhistory2heartsurgery"></td>
</tr>
<tr>
<td colspan="4"><b>Pneumonia, bronchitis or chronic cough</b>
</td>
<td colspan="2" id="healthhistory2chroniccough" name="healthhistory2chroniccough"></td>
</tr>
<tr>
<td colspan="4"><b>Asthma</b>
</td>
<td colspan="2" id="healthhistory2asthma" name="healthhistory2asthma"></td>
</tr>
<tr>
<td colspan="4"><b>Hay fever / sinus problems</b>
</td>
<td colspan="2" id="healthhistory2hayfever" name="healthhistory2hayfever"></td>
</tr>
<tr>
<td colspan="4"><b>Snoring</b>
</td>
<td colspan="2" id="healthhistory2snoring" name="healthhistory2snoring"></td>
</tr>
<tr>
<td colspan="4"><b>Sleep Apnea / CPAP</b>
</td>
<td colspan="2" id="healthhistory2sleepapnea" name="healthhistory2sleepapnea"></td>
</tr>
<tr>
<td colspan="4"><b>Difficult breathing / other lung trouble</b>
</td>
<td colspan="2" id="healthhistory2difficultbreathing" name="healthhistory2difficultbreathing"></td>
</tr>
<tr>
<td colspan="4"><b>Tuberculosis</b>
</td>
<td colspan="2" id="healthhistory2tuberculosis" name="healthhistory2tuberculosis"></td>
</tr>
<tr>
<td colspan="4"><b>Emphysema</b>
</td>
<td colspan="2" id="healthhistory2emphysema" name="healthhistory2emphysema"></td>
</tr>
<tr>
<td colspan="4"><b>Do you smoke or vape?</b>
</td>
<td colspan="2" id="healthhistory2vape" name="healthhistory2vape"></td>
</tr>
<tr>
<td colspan="4"><b>If so, how much a day?</b>
</td>
<td colspan="2" id="healthhistory2vapehowmuch" name="healthhistory2vapehowmuch"></td>
</tr>
<tr>
<td colspan="4"><b>Do you use chewing tobacco?</b>
</td>
<td colspan="2" id="healthhistory2tobacco" name="healthhistory2tobacco"></td>
</tr>
<tr>
<td colspan="4"><b>Blood transfusion</b>
</td>
<td colspan="2" id="healthhistory2bloodtransfusion" name="healthhistory2bloodtransfusion"></td>
</tr>
<tr>
<td colspan="4"><b>Blood disorder such as anemia</b>
</td>
<td colspan="2" id="healthhistory2anemia" name="healthhistory2anemia"></td>
</tr>
<tr>
<td colspan="4"><b>Bruise easily</b>
</td>
<td colspan="2" id="healthhistory2bruiseeasily" name="healthhistory2bruiseeasily"></td>
</tr>
<tr>
<td colspan="4"><b>Bleeding tendency / abnormal bleed</b>
</td>
<td colspan="2" id="healthhistory2bleedingtendency" name="healthhistory2bleedingtendency"></td>
</tr>
<tr>
<td colspan="4"><b>Hepatitis, jaundice, or liver disease</b>
</td>
<td colspan="2" id="healthhistory2hepatitis" name="healthhistory2hepatitis"></td>
</tr>
<tr>
<td colspan="4"><b>Infectious mononucleosis</b>
</td>
<td colspan="2" id="healthhistory2mononucleosis" name="healthhistory2mononucleosis"></td>
</tr>
<tr>
<td colspan="4"><b>Gallbladder trouble</b>
</td>
<td colspan="2" id="healthhistory2trouble" name="healthhistory2trouble"></td>
</tr>
<tr style="background-color: #c9ddfc;">
<td colspan="6">
<h4> Have you had or do you currently have...</h4>
</td>
</tr>
<tr>
<td colspan="4"><b>Fainting spells</b>
</td>
<td colspan="2" id="healthhistory2faintingspells" name="healthhistory2faintingspells"></td>
</tr>
<tr>
<td colspan="4"><b>Convulsions / epilepsy</b>
</td>
<td colspan="2" id="healthhistory2epilepsy" name="healthhistory2epilepsy"></td>
</tr>
<tr>
<td colspan="4"><b>Stroke</b>
</td>
<td colspan="2" id="healthhistory2stroke" name="healthhistory2stroke"></td>
</tr>
<tr>
<td colspan="4"><b>Thyroid trouble</b>
</td>
<td colspan="2" id="healthhistory2thyroidtrouble" name="healthhistory2thyroidtrouble"></td>
</tr>
<tr>
<td colspan="4"><b>Diabetes</b>
</td>
<td colspan="2" id="healthhistory2diabetes" name="healthhistory2diabetes"></td>
</tr>
<tr>
<td colspan="4"><b>Low blood sugar</b>
</td>
<td colspan="2" id="healthhistory2lowbloodsugar" name="healthhistory2lowbloodsugar"></td>
</tr>
<tr>
<td colspan="4"><b>Kidney trouble</b>
</td>
<td colspan="2" id="healthhistory2kidneytrouble" name="healthhistory2kidneytrouble"></td>
</tr>
<tr>
<td colspan="4"><b>High cholesterol</b>
</td>
<td colspan="2" id="healthhistory2cholesterol" name="healthhistory2cholesterol"></td>
</tr>
<tr>
<td colspan="4"><b>Are you on dialysis?</b>
</td>
<td colspan="2" id="healthhistory2dialysis" name="healthhistory2dialysis"></td>
</tr>
<tr>
<td colspan="4"><b>Swollen ankles, arthritis or joint disease</b>
</td>
<td colspan="2" id="healthhistory2jointdisease" name="healthhistory2jointdisease"></td>
</tr>
<tr>
<td colspan="4"><b>Osteoporosis / osteopenia</b>
</td>
<td colspan="2" id="healthhistory2osteopenia" name="healthhistory2osteopenia"></td>
</tr>
<tr>
<td colspan="4"><b>Osteonecrosis</b>
</td>
<td colspan="2" id="healthhistory2osteonecrosis" name="healthhistory2osteonecrosis"></td>
</tr>
<tr>
<td colspan="4"><b>Stomach ulcers / acid reflux</b>
</td>
<td colspan="2" id="healthhistory2acidreflux" name="healthhistory2acidreflux"></td>
</tr>
<tr>
<td colspan="4"><b>Contagious diseases</b>
</td>
<td colspan="2" id="healthhistory2contagiousdiseases" name="healthhistory2contagiousdiseases"></td>
</tr>
<tr>
<td colspan="4"><b>Sexually transmitted disease</b>
</td>
<td colspan="2" id="healthhistory2sexuallytransmitteddisease"
name="healthhistory2sexuallytransmitteddisease"></td>
</tr>
<tr>
<td colspan="4"><b>Problems with the immune system? Possibly from medication / surgery, etc.</b>
</td>
<td colspan="2" id="healthhistory2problems" name="healthhistory2problems"></td>
</tr>
<tr>
<td colspan="4"><b>Delay in healing</b>
</td>
<td colspan="2" id="healthhistory2healing" name="healthhistory2healing"></td>
</tr>
<tr>
<td colspan="4"><b>A tumor or growth</b>
</td>
<td colspan="2" id="healthhistory2growth" name="healthhistory2growth"></td>
</tr>
<tr>
<td colspan="4"><b>Cancer, radiation therapy or chemotherapy</b>
</td>
<td colspan="2" id="healthhistory2chemotherapy" name="healthhistory2chemotherapy"></td>
</tr>
<tr>
<td colspan="4"><b>Chronic fatigue / night sweats</b>
</td>
<td colspan="2" id="healthhistory2chronicfatigue" name="healthhistory2chronicfatigue"></td>
</tr>
<tr>
<td colspan="4"><b>Are you on a diet?</b>
</td>
<td colspan="2" id="healthhistory2diet" name="healthhistory2diet"></td>
</tr>
<tr>
<td colspan="4"><b>A history of alcohol abuse</b>
</td>
<td colspan="2" id="healthhistory2alcoholabuse" name="healthhistory2alcoholabuse"></td>
</tr>
<tr>
<td colspan="4"><b>A history of marijuana or other drug use?</b>
</td>
<td colspan="2" id="healthhistory2druguse" name="healthhistory2druguse"></td>
</tr>
<tr>
<td colspan="4"><b>Contact lenses</b>
</td>
<td colspan="2" id="healthhistory2contactlenses" name="healthhistory2contactlenses"></td>
</tr>
<tr>
<td colspan="4"><b>Eye disease / glaucoma</b>
</td>
<td colspan="2" id="healthhistory2eyedisease" name="healthhistory2eyedisease"></td>
</tr>
<tr>
<td colspan="4"><b>Mental health problems / anxiety / depression</b>
</td>
<td colspan="2" id="healthhistory2mentalhealth" name="healthhistory2mentalhealth"></td>
</tr>
<tr>
<td colspan="4"><b>Removable dental appliance</b>
</td>
<td colspan="2" id="healthhistory2dentalappliance" name="healthhistory2dentalappliance"></td>
</tr>
<tr>
<td colspan="4"><b>Pain and clicking of jaws when eating</b>
</td>
<td colspan="2" id="healthhistory2wheneating" name="healthhistory2dentalappliance"></td>
</tr>
</table>
<table>
<tr style="background-color: #5778b1;color:white">
<td colspan="6">
<h3>Medications / Allergies</h3>
</td>
</tr>
<tr style="background-color: #c9ddfc;">
<td colspan="6">
<h4> Medications (Are you now taking...)</h4>
</td>
</tr>
<tr>
<td colspan="4"><b>Blood thinners (Coumadin, Plavix, Aspirin, Vitamin E, Ginko biloba, Aggrenox, Pradaxa,
Fish oil)</b>
</td>
<td colspan="2" id="medicationbloodthinners" name="medicationbloodthinners"></td>
</tr>
<tr>
<td colspan="4" style="width: 66.66%;"><b>Have you ever taken diet pills</b>
</td>
<td colspan="2" id="medicationdietpills" name="medicationdietpills"></td>
</tr>
<tr>
<td colspan="4"><b>Any natural product, herbal supplement or homeopathic remedy</b>
</td>
<td colspan="2" id="medicationanynaturalproduct" name="medicationanynaturalproduct"></td>
</tr>
<tr>
<td colspan="4"><b>Are you taking, or have you ever taken bone density meds, RANKL inhibitors or
bisphosphonates such as Denosumab, Fosamax, Boniva, Actonel, IV-Zometa, Aredia, Reclast, or Evista
in the past 12 years?</b>
</td>
<td colspan="2" id="medication12years" name="medication12years"></td>
</tr>
<tr>
<td colspan="6"><b>Have you ever taken tranquilizers, sleeping pills, anti-depressants and/or narcotics on a
regular basis. If yes, please list:</b></td>
</tr>
<tr>
<td colspan="6" id="medicationlist" name="medicationlist"></td>
</tr>
<tr>
<td colspan="6"><b>If you are under the care of a physician for pain management, or recovering from drug
addiction please select the medication you are currently taking:</b></td>
</tr>
<tr>
<td colspan="4"><b>Methadone</b></td>
<td colspan="2" id="methadone" name="methadone"></td>
</tr>
<tr>
<td colspan="4"><b>Suboxone</b></td>
<td colspan="2" id="suboxone" name="suboxone"></td>
</tr>
<tr>
<td colspan="4"><b>Oxycodone</b></td>
<td colspan="2" id="oxycodone" name="oxycodone"></td>
</tr>
<tr>
<td colspan="4"><b>Fentanyl</b></td>
<td colspan="2" id="fentanyl" name="fentanyl"></td>
</tr>
<tr>
<td colspan="4"><b>Other</b></td>
<td colspan="2" id="other" name="other"></td>
</tr>
<tr>
<td colspan="6" id="otherdescription" name="otherdescription"></td>
</tr>
<tr>
<td colspan="3"><b>Treating Doctor First Name</b></td>
<td colspan="3"><b>Treating Doctor Last Name</b></td>
</tr>
<tr>
<td colspan="3" id="treatingdoctorfirstname" name="treatingdoctorfirstname"></td>
<td colspan="3" id="treatingdoctorlastname" name="treatingdoctorlastname"></td>
</tr>
<tr style="background-color: #c9ddfc;">
<td colspan="6">
<h4>Are you allergic or had a reaction to:</h4>
</td>
</tr>
<tr>
<td colspan="4"><b>Local anesthetic (numbing medication)</b></td>
<td colspan="2" id="localanesthetic" name="localanesthetic"></td>
</tr>
<tr>
<td colspan="4"><b>Penicillin</b></td>
<td colspan="2" id="penicillin" name="penicillin"></td>
</tr>
<tr>
<td colspan="4"><b>Other antibiotics</b></td>
<td colspan="2" id="otherantibiotics" name="otherantibiotics"></td>
</tr>
<tr>
<td colspan="4"><b>Sulfa Drugs</b></td>
<td colspan="2" id="sulfadrugs" name="sulfadrugs"></td>
</tr>
<tr>
<td colspan="4"><b>Sodium pentothal, Valium, or other tranquilizers</b></td>
<td colspan="2" id="tranquilizers" name="tranquilizers"></td>
</tr>
<tr>
<td colspan="4"><b>Aspirin</b></td>
<td colspan="2" id="aspirin" name="aspirin"></td>
</tr>
<tr>
<td colspan="4"><b>Amoxicillin</b></td>
<td colspan="2" id="amoxicillin" name="amoxicillin"></td>
</tr>
<tr>
<td colspan="4"><b>Codeine or other narcotics</b></td>
<td colspan="2" id="othernarcotics" name="othernarcotics"></td>
</tr>
<tr>
<td colspan="4"><b>Latex</b></td>
<td colspan="2" id="latex" name="latex"></td>
</tr>
<tr>
<td colspan="4"><b>Soy</b></td>
<td colspan="2" id="soy" name="soy"></td>
</tr>
<tr>
<td colspan="4"><b>Eggs/Yolk</b></td>
<td colspan="2" id="eggs" name="eggs"></td>
</tr>
<tr>
<td colspan="4"><b>Sulfites</b></td>
<td colspan="2" id="sulfites" name="sulfites"></td>
</tr>
<tr>
<td colspan="4"><b>Do you have any known allergies?</b></td>
<td colspan="2" id="knownallergies" name="knownallergies"></td>
</tr>
<tr>
<td colspan="6"><b>Please list any allergies other than drug allergies:</b></td>
</tr>
<tr>
<td colspan="6" id="drugallergies" name="drugallergies"></td>
</tr>
<tr>
<td colspan="4"><b>Are you taking any kind of medication, drug, pills?</b></td>
<td colspan="2" id="takingmedicationdrugpills" name="takingmedicationdrugpills"></td>
</tr>
<tr style="background-color: #c9ddfc;">
<td colspan="6">
<h4> Please list any medications you are currently taking</h4>
</td>
</tr>
<tr>
<td colspan="6"><b>Medication Name #1</b></td>
</tr>
<tr>
<td colspan="6" id="medicationname1" name="medicationname1"></td>
</tr>
<tr>
<td colspan="3"><b>Dosage</b></td>
<td colspan="3"><b>Frequency</b></td>
</tr>
<tr>
<td colspan="3" id="dosage1" name="dosage1"></td>
<td colspan="3" id="frequency1" name="frequency1"></td>
</tr>
<tr>
<td colspan="6"><b>Medication Name #2</b></td>
</tr>
<tr>
<td colspan="6" id="medicationname2" name="medicationname2"></td>
</tr>
<tr>
<td colspan="3" style="width: 50%;"><b>Dosage</b></td>
<td colspan="3"><b>Frequency</b></td>
</tr>
<tr>
<td colspan="3" id="dosage2" name="dosage2"></td>
<td colspan="3" id="frequency2" name="frequency2"></td>
</tr>
<tr>
<td colspan="6"><b>Medication Name #3</b></td>
</tr>
<tr>
<td colspan="6" id="medicationname3" name="medicationname3"></td>
</tr>
<tr>
<td colspan="3"><b>Dosage</b></td>
<td colspan="3"><b>Frequency</b></td>
</tr>
<tr>
<td colspan="3" id="dosage3" name="dosage3"></td>
<td colspan="3" id="frequency3" name="frequency3"></td>
</tr>
<tr>
<td colspan="6"><b>Medication Name #4</b></td>
</tr>
<tr>
<td colspan="6" id="medicationname4" name="medicationname4"></td>
</tr>
<tr>
<td colspan="3"><b>Dosage</b></td>
<td colspan="3"><b>Frequency</b></td>
</tr>
<tr>
<td colspan="3" id="dosage4" name="dosage4"></td>
<td colspan="3" id="frequency4" name="frequency4"></td>
</tr>
<tr>
<td colspan="6"><b>Medication Name #5</b></td>
</tr>
<tr>
<td colspan="6" id="medicationname5" name="medicationname5"></td>
</tr>
<tr>
<td colspan="3"><b>Dosage</b></td>
<td colspan="3"><b>Frequency</b></td>
</tr>
<tr>
<td colspan="3" id="dosage5" name="dosage5"></td>
<td colspan="3" id="frequency5" name="frequency5"></td>
</tr>
<tr>
<td colspan="6"><b>Medication Name #6</b></td>
</tr>
<tr>
<td colspan="6" id="medicationname6" name="medicationname6"></td>
</tr>
<tr>
<td colspan="3"><b>Dosage</b></td>
<td colspan="3"><b>Frequency</b></td>
</tr>
<tr>
<td colspan="3" id="dosage6" name="dosage6"></td>
<td colspan="3" id="frequency6" name="frequency6"></td>
</tr>
<tr>
<td colspan="6"><b>Medication Name #7</b></td>
</tr>
<tr>
<td colspan="6" id="medicationname7" name="medicationname7"></td>
</tr>
<tr>
<td colspan="3"><b>Dosage</b></td>
<td colspan="3"><b>Frequency</b></td>
</tr>
<tr>
<td colspan="3" id="dosage7" name="dosage7"></td>
<td colspan="3" id="frequency7" name="frequency7"></td>
</tr>
<tr>
<td colspan="6"><b>Medication Name #8</b></td>
</tr>
<tr>
<td colspan="6" id="medicationname8" name="medicationname8"></td>
</tr>
<tr>
<td colspan="3"><b>Dosage</b></td>
<td colspan="3"><b>Frequency</b></td>
</tr>
<tr>
<td colspan="3" id="dosage8" name="dosage8"></td>
<td colspan="3" id="frequency8" name="frequency8"></td>
</tr>
<tr>
<td colspan="6"><b>Medication Name #9</b></td>
</tr>
<tr>
<td colspan="6" id="medicationname9" name="medicationname9"></td>
</tr>
<tr>
<td colspan="3"><b>Dosage</b></td>
<td colspan="3"><b>Frequency</b></td>
</tr>
<tr>
<td colspan="3" id="dosage9" name="dosage9"></td>
<td colspan="3" id="frequency9" name="frequency9"></td>
</tr>
<tr>
<td colspan="6"><b>Medication Name #10</b></td>
</tr>
<tr>
<td colspan="6" id="medicationname10" name="medicationname10"></td>
</tr>
<tr>
<td colspan="3"><b>Dosage</b></td>
<td colspan="3"><b>Frequency</b></td>
</tr>
<tr>
<td colspan="3" id="dosage10" name="dosage10"></td>
<td colspan="3" id="frequency10" name="frequency10"></td>
</tr>
<tr>
<td colspan="6"><b>Medication Name #11</b></td>
</tr>
<tr>
<td colspan="6" id="medicationname11" name="medicationname11"></td>
</tr>
<tr>
<td colspan="3"><b>Dosage</b></td>
<td colspan="3"><b>Frequency</b></td>
</tr>
<tr>
<td colspan="3" id="dosage11" name="dosage11"></td>
<td colspan="3" id="frequency11" name="frequency11"></td>
</tr>
<tr>
<td colspan="6"><b>Medication Name #12</b></td>
</tr>
<tr>
<td colspan="6" id="medicationname12" name="medicationname12"></td>
</tr>
<tr>
<td colspan="3"><b>Dosage</b></td>
<td colspan="3"><b>Frequency</b></td>
</tr>
<tr>
<td colspan="3" id="dosage12" name="dosage12"></td>
<td colspan="3" id="frequency12" name="frequency12"></td>
</tr>
<tr>
<td colspan="6"><b>Medication Name #13</b></td>
</tr>
<tr>
<td colspan="6" id="medicationname13" name="medicationname13"></td>
</tr>
<tr>
<td colspan="3"><b>Dosage</b></td>
<td colspan="3"><b>Frequency</b></td>
</tr>
<tr>
<td colspan="3" id="dosage13" name="dosage13"></td>
<td colspan="3" id="frequency13" name="frequency13"></td>
</tr>
<tr>
<td colspan="6"><b>Medication Name #14</b></td>
</tr>
<tr>
<td colspan="6" id="medicationname14" name="medicationname14"></td>
</tr>
<tr>
<td colspan="3"><b>Dosage</b></td>
<td colspan="3"><b>Frequency</b></td>
</tr>
<tr>
<td colspan="3" id="dosage14" name="dosage14"></td>
<td colspan="3" id="frequency14" name="frequency14"></td>
</tr>
<tr>
<td colspan="6"><b>Medication Name #15</b></td>
</tr>
<tr>
<td colspan="6" id="medicationname15" name="medicationname15"></td>
</tr>
<tr>
<td colspan="3"><b>Dosage</b></td>
<td colspan="3"><b>Frequency</b></td>
</tr>
<tr>
<td colspan="3" id="dosage15" name="dosage15"></td>
<td colspan="3" id="frequency15" name="frequency15"></td>
</tr>
<tr>
<td colspan="6"><b>Medication Name #16</b></td>
</tr>
<tr>
<td colspan="6" id="medicationname16" name="medicationname16"></td>
</tr>
<tr>
<td colspan="3"><b>Dosage</b></td>
<td colspan="3"><b>Frequency</b></td>
</tr>
<tr>
<td colspan="3" id="dosage16" name="dosage16"></td>
<td colspan="3" id="frequency16" name="frequency16"></td>
</tr>
<tr>
<td colspan="6"><b>Medication Name #17</b></td>
</tr>
<tr>
<td colspan="6" id="medicationname17" name="medicationname17"></td>
</tr>
<tr>
<td colspan="3"><b>Dosage</b></td>
<td colspan="3"><b>Frequency</b></td>
</tr>
<tr>
<td colspan="3" id="dosage17" name="dosage17"></td>
<td colspan="3" id="frequency17" name="frequency17"></td>
</tr>
<tr>
<td colspan="6"><b>Medication Name #18</b></td>
</tr>
<tr>
<td colspan="6" id="medicationname18" name="medicationname18"></td>
</tr>
<tr>
<td colspan="3"><b>Dosage</b></td>
<td colspan="3"><b>Frequency</b></td>
</tr>
<tr>
<td colspan="3" id="dosage18" name="dosage18"></td>
<td colspan="3" id="frequency18" name="frequency18"></td>
</tr>
<tr>
<td colspan="6"><b>Medication Name #19</b></td>
</tr>
<tr>
<td colspan="6" id="medicationname19" name="medicationname19"></td>
</tr>
<tr>
<td colspan="3"><b>Dosage</b></td>
<td colspan="3"><b>Frequency</b></td>
</tr>
<tr>
<td colspan="3" id="dosage19" name="dosage19"></td>
<td colspan="3" id="frequency19" name="frequency19"></td>
</tr>
<tr>
<td colspan="6"><b>Medication Name #20</b></td>
</tr>
<tr>
<td colspan="6" id="medicationname20" name="medicationname20"></td>
</tr>
<tr>
<td colspan="3"><b>Dosage</b></td>
<td colspan="3"><b>Frequency</b></td>
</tr>
<tr>
<td colspan="3" id="dosage20" name="dosage20"></td>
<td colspan="3" id="frequency20" name="frequency20"></td>
</tr>
<tr style="background-color: #c9ddfc;">
<td colspan="6">
<h4> Please list any other medications or antibiotics you are allergic to</h4>
</td>
</tr>
<tr>
<td colspan="6"><b>Medication / Antibiotic Name Allergy #1</b></td>
</tr>
<tr>
<td colspan="6" id="medicationantibioticnameallergy1" name="medicationantibioticnameallergy1"></td>
</tr>
<tr>
<td colspan="6"><b>Medication / Antibiotic Name Allergy #2</b></td>
</tr>
<tr>
<td colspan="6" id="medicationantibioticnameallergy2" name="medicationantibioticnameallergy2"></td>
</tr>
<tr>
<td colspan="6"><b>Medication / Antibiotic Name Allergy #3</b></td>
</tr>
<tr>
<td colspan="6" id="medicationantibioticnameallergy3" name="medicationantibioticnameallergy3"></td>
</tr>
<tr>
<td colspan="6"><b>Medication / Antibiotic Name Allergy #4</b></td>
</tr>
<tr>
<td colspan="6" id="medicationantibioticnameallergy4" name="medicationantibioticnameallergy4"></td>
</tr>
<tr>
<td colspan="6"><b>Medication / Antibiotic Name Allergy #5</b></td>
</tr>
<tr>
<td colspan="6" id="medicationantibioticnameallergy5" name="medicationantibioticnameallergy5"></td>
</tr>
<tr>
<td colspan="6"><b>Medication / Antibiotic Name Allergy #6</b></td>
</tr>
<tr>
<td colspan="6" id="medicationantibioticnameallergy6" name="medicationantibioticnameallergy6"></td>
</tr>
<tr>
<td colspan="6"><b>Medication / Antibiotic Name Allergy #7</b></td>
</tr>
<tr>
<td colspan="6" id="medicationantibioticnameallergy7" name="medicationantibioticnameallergy7"></td>
</tr>
<tr>
<td colspan="6"><b>Medication / Antibiotic Name Allergy #8</b></td>
</tr>
<tr>
<td colspan="6" id="medicationantibioticnameallergy8" name="medicationantibioticnameallergy8"></td>
</tr>
<tr>
<td colspan="6"><b>Medication / Antibiotic Name Allergy #9</b></td>
</tr>
<tr>
<td colspan="6" id="medicationantibioticnameallergy9" name="medicationantibioticnameallergy9"></td>
</tr>
<tr>
<td colspan="6"><b>Medication / Antibiotic Name Allergy #10</b></td>
</tr>
<tr>
<td colspan="6" id="medicationantibioticnameallergy10" name="medicationantibioticnameallergy10"></td>
</tr>
</table>
<table>
<tr style="background-color: #5778b1;color:white">
<td colspan="6">
<h3>Conclusion</h3>
</td>
</tr>
<tr style="background-color: #c9ddfc;">
<td colspan="6">
<h4> Is there a family history of</h4>
</td>
</tr>
<tr>
<td colspan="4" style="width: 66.66%;"><b>Cancer</b></td>
<td colspan="2" id="isthereafamilyhistoryofcancer" name="isthereafamilyhistoryofcancer"></td>
</tr>
<tr>
<td colspan="4"><b>Diabetes</b></td>
<td colspan="2" id="isthereafamilyhistoryofdiabetes" name="isthereafamilyhistoryofdiabetes"></td>
</tr>
<tr>
<td colspan="4"><b>Heart Disease</b></td>
<td colspan="2" id="isthereafamilyhistoryofheartdisease" name="isthereafamilyhistoryofheartdisease"></td>
</tr>
<tr>
<td colspan="4"><b>Anesthesia Problems</b></td>
<td colspan="2" id="isthereafamilyhistoryofanesthesiaproblems"
name="isthereafamilyhistoryofanesthesiaproblems"></td>
</tr>
<tr style="background-color: #c9ddfc;">
<td colspan="6">
<h4>In case of emergency</h4>
</td>
</tr>
<tr>
<td colspan="6"><b>Emergency Contact Full Name</b></td>
</tr>
<tr>
<td colspan="6" id="emergencycontactfullname" name="emergencycontactfullname"></td>
</tr>
<tr>
<td colspan="3" style="width: 50%;"><b>Home Phone</b></td>
<td colspan="3"><b>Relation to Patient</b></td>
</tr>
<tr>
<td colspan="3" id="emergencycontacthomephone" name="emergencycontacthomephone"></td>
<td colspan="3" id="emergencycontactrelationtopatient" name="emergencycontactrelationtopatient"></td>
</tr>
<tr style="background-color:#c9ddfc;">
<td colspan="6">
<h4>Is this related to an accident?</h4>
</td>
</tr>
<tr>
<td colspan="4"><b>Is this related to an accident? </b></td>
<td colspan="2" id="isthisrelatedtoanaccident" name="isthisrelatedtoanaccident"></td>
</tr>
<tr>
<td colspan="6"><b>If Yes, What type?</b></td>
</tr>
<tr>
<td colspan="6" id="ifyeswhattype" name="ifyeswhattype"></td>
</tr>
<tr>
<td colspan="6"><b>Date of Injury</b></td>
</tr>
<tr>
<td colspan="6" id="dateofinjury" name="dateofinjury"></td>
</tr>
<tr>
<td colspan="6"><b>Insurance company handling this claim</b></td>
</tr>
<tr>
<td colspan="6" id="insurancecompanyhandlingthisclaim" name="insurancecompanyhandlingthisclaim"></td>
</tr>
<tr>
<td colspan="6"><b>Insurance claim number</b></td>
</tr>
<tr>
<td colspan="6" id="insuranceclaimnumber" name="insuranceclaimnumber"></td>
</tr>
<tr>
<td colspan="6"><b>Name of Attorney/Adjustor</b></td>
</tr>
<tr>
<td colspan="6" id="nameofattorneyadjustor" name="nameofattorneyadjustor"></td>
</tr>
<tr>
<td colspan="6"><b>Attorney/Adjustor Phone</b></td>
</tr>
<tr>
<td colspan="6" id="attorneyadjustorphone" name="attorneyadjustorphone"></td>
</tr>
<tr style="background-color: #c9ddfc;">
<td colspan="6">
<h4>Verification</h4>
</td>
</tr>
<tr>
<td colspan="6">I certify that I have read and I understand the questions above. I acknowledge that my
questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not
hold my doctor, or any other member of his / her staff, responsible for any errors or omissions that I
have made in the completion of this form.
</td>
</tr>
<tr>
<td colspan="3" id="signature1" name="signature1">${image_ar[0] ? `<img src="${image1}" alt="logo" width="100px">` : ""}</td>
<td colspan="1">Date</td>
<td colspan="2" id="signaturedate1" name="signaturedate1"></td>
</tr>
<tr>
<td colspan="6">
<b>FEES & PAYMENTS </b>
</td>
</tr>
<tr>
<td colspan="6">We make every effort to keep down the cost of your care. You can help by paying upon
completion of each
visit. Other arrangements can be made with our office manager depending upon special circumstances. An
estimate of the charge for any procedure or surgery you may require will be given to you upon request.
If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please
complete the identifying information on this form.
Please remember that insurance is considered a method of reimbursing the patient for fees paid to the
doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures
and others pay a percentage of the charge. It is your responsibility to pay any deductible amount,
co-insurance or any other balance not paid for by your insurance company. You will be responsible for
all collection costs, attorneys fees, and court costs.
</td>
</tr>
<tr>
<td colspan="3" id="signature2" name="signature2">${image_ar[1] ? `<img src="${image2}" alt="logo" width="100px">` : ""}</td>
<td colspan="1">Date</td>
<td colspan="2" id="signaturedate2" name="signaturedate2"></td>
</tr>
<tr>
<td colspan="6">This signature on file is my authorization for the release of information necessary to
process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to
me.
</td>
</tr>
<tr>
<td colspan="3" id="signature2" name="signature2">${image_ar[2] ? `<img src="${image3}" alt="logo" width="100px">` : ""}</td>
<td colspan="1">Date</td>
<td colspan="2" id="signaturedate2" name="signaturedate2"></td>
</tr>
<tr>
<td colspan="6">I authorize my surgeon and his / her designated staff, to perform an oral and maxillofacial
examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of
all x–rays required as a necessary part of this examination. In addition, if medically necessary, I
authorize the release of any information acquired in the course of my examination and treatment to my
other doctors and/or insurance carriers. I permit messages to be left on my phone and / or mobile phone
concerning my appointment.
</td>
</tr>
<tr>
<td colspan="3" id="signature3" name="signature3">${image_ar[3] ? `<img src="${image4}" alt="logo" width="100px">` : ""}</td>
<td colspan="1">Date</td>
<td colspan="2" id="signaturedate3" name="signaturedate3"></td>
</tr>
<tr>
<td colspan="6">I hereby acknowledge that a copy of this office’s Notice of Privacy Practices has been made
available to me. I have been given the opportunity to ask any questions I may have regarding this
Notice.
</td>
</tr>
<tr>
<td colspan="3" id="signature4" name="signature4">${image_ar[4] ? `<img src="${image5}" alt="logo" width="100px">` : ""}</td>
<td colspan="1">Date</td>
<td colspan="2" id="signaturedate4" name="signaturedate4"></td>
</tr>
</table>
</body>
</html>`;
var options = {
format: 'Letter',
// Script options
"phantomPath": "./node_modules/phantomjs/bin/phantomjs", // PhantomJS binary which should get downloaded automatically
"phantomArgs": [], // array of strings used as phantomjs args e.g. ["--ignore-ssl-errors=yes"]
"timeout": 30000, // Timeout that will cancel phantomjs, in milliseconds
};
pdf.create(html, options).toFile('./table.pdf', function (err, res) {
if (err) {
return console.log(err);
}
else {
console.log(res);
//email the saved pdf file
var mailOptions = {
from: 'youremail@gmail.com',
// to: 'anoop.u@cabotsolutions.com',
to: 'muneeb.mukhthar@cabotsolutions.com',
subject: 'PDF file sample',
text: 'That was easy! Another one',
attachments: [
{ // use URL as an attachment
filename: 'table.pdf',
path: './table.pdf'
}
]
};
transporter.sendMail(mailOptions, function (error, info) {
if (error) {
console.log(error);
} else {
console.log('Email sent: ' + info.response);
}
});
}
});
return "success";
}
async function uploadCanvasImage(data, callback) {
var image_ar_ful = [];
//console.log(data)
var fileSavePromise = Promise.resolve(image_ar_ful);
data.forEach(function (element, index) {
var newIndex = index + 1;
var timestamp = Date.now();
var image = element.image;
if (image) {
var base64Data = image.replace(/^data:image\/png;base64,/, "");
image_ar_ful.push("signature_" + newIndex + "_" + timestamp + ".png")
fileSavePromise = new Promise(function (resolve, reject) {
require("fs").writeFile("./signatures/signature_" + newIndex + "_" + timestamp + ".png", base64Data, 'base64', function (err) {
if (err) console.log(err);
else {
console.log("file successfully saved")
resolve(image_ar_ful)
}
});
})
} else {
image_ar_ful.push("");
}
})
fileSavePromise.then(function (res) {
var ret = convertHtmlToPdf(res);
return ret;
}).then(function(final){
if(final == "success"){
return callback('1', 'form submitted successfully', '', '');
}
else {
return callback('0', 'form submitted with errors', '', '');
}
});
}
Sign up for free to join this conversation on GitHub. Already have an account? Sign in to comment