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Patient Demographics Form
Please COMPLETE and SUBMIT the following Patient Demographics Form prior to arrival at the Occucare Clinic closest to your location.
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="First_Name"
as=${html``}
/>
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Last_Name"
as=${html``}
/>
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Nick_Name"
as=${html``}
/>
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="City"
as=${html``}
/>
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Zip"
as=${html``}
/>
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="state-text"
as=${html``}
/>
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Street_Address"
as=${html``}
/>
<${props.ReactPhoneInput}
inputProps=${{
name: "Hm_Phone"
}}
inputExtraProps=${{
required: true,
autoFocus: true,
}}
key=${parent.state.resetKey}
searchPlaceholder="Search"
inputClass="mf-input mf-input-mobile"
country="us"
enableSearch=${true}
countryCodeEditable=${false}
enableAreaCodes=${false}
value=${parent.state.mobileWidget["Hm_Phone"] ? parent.state.mobileWidget["Hm_Phone"] :
(parent.state.formData["Hm_Phone"] ? parent.state.formData["Hm_Phone"] : '')}
}
name="Hm_Phone"
id="mf-input-mobile-4844179"
onChange=${(value, country) => {
return parent.handleOnChangePhoneInput(value, "Hm_Phone", country)
} }
onBlur=${(event, country) => {
let value = event.target.value;
if(value && "no" != "yes"){
value = value.replace(/[^\d]/g, '');
}
parent.handleOnChangePhoneInput(value, "Hm_Phone", country)
} }
/>
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false}, el) }
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Hm_Phone"
as=${html``}
/>
<${props.ReactPhoneInput}
inputProps=${{
name: "mobile-number"
}}
inputExtraProps=${{
required: true,
autoFocus: true,
}}
key=${parent.state.resetKey}
searchPlaceholder="Search"
inputClass="mf-input mf-input-mobile"
country="us"
enableSearch=${true}
countryCodeEditable=${false}
enableAreaCodes=${false}
value=${parent.state.mobileWidget["mobile-number"] ? parent.state.mobileWidget["mobile-number"] :
(parent.state.formData["mobile-number"] ? parent.state.formData["mobile-number"] : '')}
}
name="mobile-number"
id="mf-input-mobile-7333d4a"
onChange=${(value, country) => {
return parent.handleOnChangePhoneInput(value, "mobile-number", country)
} }
onBlur=${(event, country) => {
let value = event.target.value;
if(value && "no" != "yes"){
value = value.replace(/[^\d]/g, '');
}
parent.handleOnChangePhoneInput(value, "mobile-number", country)
} }
/>
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false}, el) }
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="mobile-number"
as=${html``}
/>
parent.activateValidation({"message":"This field is required.","emailMessage":"Please enter a valid Email address","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="email-address"
as=${html``}
/>
<${props.Flatpickr}
name="Date_of_birth"
className="mf-input mf-date-input mf-left-parent "
placeholder="${ parent.decodeEntities(`MM-DD-YEAR`) } "
options=${{"minDate":"","maxDate":"","dateFormat":"m-d-Y","enableTime":"","disable":["01-01-1970"],"mode":"single","static":true,"disableMobile":true,"time_24hr":false}}
value=${parent.getValue('Date_of_birth')}
onInput=${parent.handleDateTime}
aria-invalid=${validation.errors['Date_of_birth'] ? 'true' : 'false'}
ref=${el => props.DateWidget(
el,
'',
{"message":"This field is required.","required":false},
register,
parent
)}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Date_of_birth"
as=${html``}
/>
parent.handleCheckbox(el, 'onLoad')}
className="mf-checkbox multi-option-input-type"
id="mf-input-checkbox-da8cacb">
<${validation.ErrorMessage}
errors=${validation.errors}
name="Race"
as=${html``}
/>
<${props.Select}
className=${"mf-input mf-input-select " + ( validation.errors['Preferred_Language'] ? 'mf-invalid' : '' )}
classNamePrefix="mf_select"
name="Preferred_Language"
placeholder="${ parent.decodeEntities(``) } "
isSearchable=${false}
options=${[{"label":"English","value":"English","isDisabled":false},{"label":"Spanish","value":"Spanish","isDisabled":false}]}
value=${parent.getValue("Preferred_Language") ? [{"label":"English","value":"English","isDisabled":false},{"label":"Spanish","value":"Spanish","isDisabled":false}].filter(item => item.value === parent.getValue("Preferred_Language"))[0] : []}
onChange=${(e)=> parent.handleSelect(e, "Preferred_Language")}
ref=${() => {
register({ name: "Preferred_Language" }, parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":true}));
if ( parent.getValue("Preferred_Language") === '' && false ) {
parent.setValue( 'Preferred_Language', '', true );
parent.handleChange({
target: {
name: 'Preferred_Language',
value: ''
}
});
}
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Preferred_Language"
as=${html``}
/>
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Drivers_License_No_"
as=${html``}
/>
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="DL_Class"
as=${html``}
/>
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Issuing_State"
as=${html``}
/>
Please read the following statement and if you agree, sign and date.
“I declare that the above information and medical history to be true to the best of my knowledge.”
“I agree to the release of information related to my fitness for duty, accommodations that may be needed for me to perform essential job functions and/or prognosis for a return to employment.
You may refuse to sign this authorization. However, a refusal to sign this the authorization may have employment consequences.”
parent.handleCheckbox(el, 'onLoad')}
className="mf-checkbox multi-option-input-type"
id="mf-input-checkbox-36c3c08">
<${validation.ErrorMessage}
errors=${validation.errors}
name="Medical_Authorization"
as=${html``}
/>
“We are required to provide you with a copy of our notice of privacy practices, which states how we may use and/or disclose your health information. Please sign this form to acknowledge receipt of the notice.
parent.handleCheckbox(el, 'onLoad')}
className="mf-checkbox multi-option-input-type"
id="mf-input-checkbox-95b8c5a">
<${validation.ErrorMessage}
errors=${validation.errors}
name="HIPAA_Notice_of_Privacy_Practices_Acceptance"
as=${html``}
/>
<${props.SignaturePad}
clearButton="true"
penColor=""
name="mf-signature"
onEnd=${function () { parent.handleSignature(this) }}
/>
parent.activateValidation({"message":"This field is required.","required":false}, el) }
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="mf-signature"
as=${html``}
/>
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="state"
as=${html``}
/>