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1205 lines
96 KiB
1205 lines
96 KiB
<?xml version="1.0" encoding="utf-8"?>
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<odoo>
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<template id="assessment_request_form">
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<!-- Template of Assessment Request Form in website-->
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<t t-call="website.layout">
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<div id="wrap" class="oe_structure oe_empty">
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<section
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class="s_title parallax s_parallax_is_fixed bg-black-50 pt24 pb24"
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data-vcss="001" data-snippet="s_title"
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data-scroll-background-ratio="1">
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<span class="s_parallax_bg oe_img_bg"
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style="background-image: url('/web/image/website.s_banner_default_image'); background-position: 50% 0;"/>
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<div class="o_we_bg_filter bg-black-50"/>
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<div class="container">
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<h1>Assessment Request Form</h1>
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</div>
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</section>
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<section class="s_website_form" data-vcss="001"
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data-snippet="s_website_form">
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<div class="container s_allow_columns">
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<div class="row">
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<div class="col-lg-8 mt-4 mt-lg-0">
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<section class="s_website_form" data-vcss="001"
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data-snippet="s_website_form">
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<div class="container">
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<form id="contactus_form"
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action="/assessment_request/submit"
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method="post"
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enctype="multipart/form-data"
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class="o_mark_required"
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data-mark="*"
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data-model_name="mail.mail"
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data-success-mode="redirect"
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data-success-page="/contactus-thank-you"
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data-pre-fill="true">
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<div class="s_website_form_rows row s_col_no_bgcolor">
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
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data-type="char"
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data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label"
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style="width: 200px"
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for="applicant_name">
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<span class="s_website_form_label_content">
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Applicant's Full
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Name:
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</span>
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</label>
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<div class="col-sm">
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<input id="applicant_name"
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type="text"
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class="form-control s_website_form_input"
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name="applicant_name"
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required=""/>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
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data-type="date"
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data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label"
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style="width: 200px"
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for="birth_date">
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<span class="s_website_form_label_content">
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Birth Date:
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</span>
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</label>
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<div class="col-sm">
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<input id="birth_date"
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type="date"
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class="form-control s_website_form_input"
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name="birth_date"
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required=""/>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
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data-type="date"
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data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label"
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style="width: 200px"
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for="male">
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<span class="s_website_form_label_content">
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Gender:
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</span>
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</label>
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<div class="col-sm">
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<input type="radio"
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id="Male"
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name="gender"
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value="Male"
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required=""/>
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<label for="Male">
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Male
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</label>
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<input type="radio"
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id="Female"
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name="gender"
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value="Female"/>
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<label for="Female">
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Female
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</label>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
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data-type="char"
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data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label"
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style="width: 200px"
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for="street">
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<span class="s_website_form_label_content">
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Applicant
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Address:
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</span>
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</label>
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<div class="col-sm">
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<input id="street"
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type="text"
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class="form-control s_website_form_input o_address_street"
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name="street"
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placeholder="Street"
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required=""/>
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<input id="city"
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type="text"
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class="form-control s_website_form_input o_address_city"
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name="city"
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placeholder="City"
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required=""/>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
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data-type="char"
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data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label"
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style="width: 200px"
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for="subject">
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<span class="s_website_form_label_content">
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Subject:
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</span>
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</label>
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<div class="col-sm">
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<input id="subject"
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type="text"
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class="form-control s_website_form_input"
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name="subject"
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required=""/>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
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data-type="char"
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data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label"
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style="width: 200px"
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for="marital_status">
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<span class="s_website_form_label_content">
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Marital Status:
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</span>
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</label>
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<div class="col-sm">
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<select id="marital_status"
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class="form-control s_website_form_input"
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name="marital_status">
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<option value="Married">
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Married
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</option>
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<option value="Single">
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Single
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</option>
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<option value="Separated">
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Separated
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</option>
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<option value="Widowed">
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Widowed
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</option>
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<option value="Divorced">
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Divorced
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</option>
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</select>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
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data-type="char"
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data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label"
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style="width: 200px"
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for="living_arrangement">
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<span class="s_website_form_label_content">
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Present Living
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Arrangements:
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</span>
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</label>
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<div class="col-sm">
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<select id="living_arrangement"
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class="form-control s_website_form_input"
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name="living_arrangement">
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<option value="With Relative">
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With
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Relative
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</option>
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<option value="With Non-Relative">
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With
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Non-Relative
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</option>
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<option value="Alone(Home/Apartment)">
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Alone(Home/Apartment)
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</option>
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<option value="Alone(Single Room)">
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Alone(Single
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Room)
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</option>
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</select>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
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data-type="char"
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data-name="Field">
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<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label"
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style="width: 200px"
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for="medicaid">
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<span class="s_website_form_label_content">
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Medicaid:
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</span>
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</label>
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<div class="col-sm">
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<input id="medicaid"
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type="number"
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class="form-control s_website_form_input"
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name="medicaid"/>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
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data-type="char"
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|
data-name="Field">
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|
<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label"
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style="width: 200px"
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for="medicare">
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<span class="s_website_form_label_content">
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Medicare:
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</span>
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</label>
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<div class="col-sm">
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<input id="medicare"
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type="number"
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class="form-control s_website_form_input"
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name="medicare"/>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
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data-type="char"
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|
data-name="Field">
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|
<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label"
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style="width: 200px"
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for="sup_sec_income">
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<span class="s_website_form_label_content">
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Supplemental
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Security Income:
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</span>
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</label>
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<div class="col-sm">
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<input id="sup_sec_income"
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type="number"
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class="form-control s_website_form_input"
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name="sup_sec_income"/>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
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data-type="char"
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data-name="Field">
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|
<div class="row s_col_no_resize s_col_no_bgcolor">
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<label class="col-form-label col-sm-auto s_website_form_label"
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style="width: 200px"
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for="why_interest">
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<span class="s_website_form_label_content">
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Tell us why you
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are interested
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in joining this
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program?:
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</span>
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</label>
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<div class="col-sm">
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<input id="why_interest"
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type="text"
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class="form-control s_website_form_input"
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name="why_interest"/>
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</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
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data-type="date"
|
|
data-name="Field">
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|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
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|
style="width: 200px"
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|
for="Yes">
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|
<span class="s_website_form_label_content">
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|
Have you had
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previous
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experience in an
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adult day care
|
|
program?:
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|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
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<input type="radio"
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id="Yes"
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name="experience"
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value="Yes"
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required=""/>
|
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<label for="Yes">
|
|
Yes
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</label>
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<input type="radio"
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id="No"
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name="experience"
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value="No"/>
|
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<label for="No">No
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</label>
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|
</div>
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</div>
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</div>
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<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="char"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
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|
style="width: 200px"
|
|
for="where_when">
|
|
<span class="s_website_form_label_content">
|
|
If yes, Where
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|
and when?:
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|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
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<input id="where_when"
|
|
type="text"
|
|
class="form-control s_website_form_input"
|
|
name="where_when"/>
|
|
</div>
|
|
</div>
|
|
</div>
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|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="char"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
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|
for="living_with_whom">
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|
<span class="s_website_form_label_content">
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|
Living with
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|
whom:
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</span>
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|
</label>
|
|
<div class="col-sm">
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<input id="living_with_whom"
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type="text"
|
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class="form-control s_website_form_input"
|
|
name="living_with_whom"
|
|
required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="char"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="relation_with_living">
|
|
<span class="s_website_form_label_content">
|
|
Relationship
|
|
with whom their
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|
living:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="relation_with_living"
|
|
type="text"
|
|
class="form-control s_website_form_input"
|
|
name="relation_with_living"
|
|
required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="char"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="nearest_relative">
|
|
<span class="s_website_form_label_content">
|
|
Nearest
|
|
responsible
|
|
relative:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="nearest_relative"
|
|
type="text"
|
|
class="form-control s_website_form_input"
|
|
name="nearest_relative"
|
|
required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="char"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="nearest_relative_relation">
|
|
<span class="s_website_form_label_content">
|
|
Relationship to
|
|
nearest
|
|
relative:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="nearest_relative_relation"
|
|
type="text"
|
|
class="form-control s_website_form_input"
|
|
name="nearest_relative_relation"
|
|
required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="char"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="employed_where">
|
|
<span class="s_website_form_label_content">
|
|
If employed,
|
|
Where:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="employed_where"
|
|
type="text"
|
|
class="form-control s_website_form_input"
|
|
name="employed_where"/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="char"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="business_phone">
|
|
<span class="s_website_form_label_content">
|
|
Business Phone:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="business_phone"
|
|
type="text"
|
|
class="form-control s_website_form_input"
|
|
name="business_phone"/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="char"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="emergency_contact_1">
|
|
<span class="s_website_form_label_content">
|
|
Emergency
|
|
Contact#1:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="emergency_contact_1"
|
|
type="text"
|
|
class="form-control s_website_form_input"
|
|
name="emergency_contact_1"
|
|
required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="char"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="applicant_relation_1">
|
|
<span class="s_website_form_label_content">
|
|
Applicant
|
|
Relationship#1:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="applicant_relation_1"
|
|
type="text"
|
|
class="form-control s_website_form_input"
|
|
name="applicant_relation_1"
|
|
required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="char"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="emergency_address_1">
|
|
<span class="s_website_form_label_content">
|
|
Emergency
|
|
Address#1:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="emergency_address_1"
|
|
type="text"
|
|
class="form-control s_website_form_input"
|
|
name="emergency_address_1"
|
|
required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="char"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="first_emergency_phone">
|
|
<span class="s_website_form_label_content">
|
|
Emergency
|
|
Phone#1:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="emergency_phone_1"
|
|
type="text"
|
|
class="form-control s_website_form_input"
|
|
name="first_emergency_phone"
|
|
required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="char"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="second_emergency_contact">
|
|
<span class="s_website_form_label_content">
|
|
Emergency
|
|
Contact#2:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="emergency_contact_2"
|
|
type="text"
|
|
class="form-control s_website_form_input"
|
|
name="second_emergency_contact"
|
|
required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="char"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="applicant_relation_2">
|
|
<span class="s_website_form_label_content">
|
|
Applicant
|
|
Relationship#2:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="applicant_relation_2"
|
|
type="text"
|
|
class="form-control s_website_form_input"
|
|
name="applicant_relation_2"
|
|
required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="char"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="emergency_address_2">
|
|
<span class="s_website_form_label_content">
|
|
Emergency
|
|
Address#2:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="emergency_address_2"
|
|
type="text"
|
|
class="form-control s_website_form_input"
|
|
name="emergency_address_2"
|
|
required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="char"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="emergency_phone_2">
|
|
<span class="s_website_form_label_content">
|
|
Emergency
|
|
Phone#2:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="emergency_phone_2"
|
|
type="text"
|
|
class="form-control s_website_form_input"
|
|
name="emergency_phone_2"
|
|
required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="char"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="physician_name">
|
|
<span class="s_website_form_label_content">
|
|
Physician Name:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="physician_name"
|
|
type="text"
|
|
class="form-control s_website_form_input"
|
|
name="physician_name"
|
|
required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="char"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="physician_address">
|
|
<span class="s_website_form_label_content">
|
|
Physician
|
|
Address:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="physician_address"
|
|
type="text"
|
|
class="form-control s_website_form_input"
|
|
name="physician_address"
|
|
required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="char"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="physician_phone">
|
|
<span class="s_website_form_label_content">
|
|
Physician Phone:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="physician_phone"
|
|
type="text"
|
|
class="form-control s_website_form_input"
|
|
name="physician_phone"
|
|
required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="date"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="physician_last_visit">
|
|
<span class="s_website_form_label_content">
|
|
Physician Last
|
|
Visit:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="physician_last_visit"
|
|
type="date"
|
|
class="form-control s_website_form_input"
|
|
name="physician_last_visit"
|
|
required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="char"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="dentist_name">
|
|
<span class="s_website_form_label_content">
|
|
Dentist Name:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="dentist_name"
|
|
type="text"
|
|
class="form-control s_website_form_input"
|
|
name="dentist_name"
|
|
required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="char"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="dentist_address">
|
|
<span class="s_website_form_label_content">
|
|
Dentist Address:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="dentist_address"
|
|
type="text"
|
|
class="form-control s_website_form_input"
|
|
name="dentist_address"
|
|
required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="char"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="dentist_phone">
|
|
<span class="s_website_form_label_content">
|
|
Dentist Phone:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="dentist_phone"
|
|
type="text"
|
|
class="form-control s_website_form_input"
|
|
name="dentist_phone"
|
|
required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="date"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="dentist_last_visit">
|
|
<span class="s_website_form_label_content">
|
|
Dentist Last
|
|
Visit:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="dentist_last_visit"
|
|
type="date"
|
|
class="form-control s_website_form_input"
|
|
name="dentist_last_visit"
|
|
required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="char"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="transport_provider">
|
|
<span class="s_website_form_label_content">
|
|
Transportation
|
|
will be provided
|
|
by:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<select id="transport_provider"
|
|
class="form-control s_website_form_input"
|
|
name="transport_provider">
|
|
<option value="Relative or Friend">
|
|
Relative or
|
|
Friend
|
|
</option>
|
|
<option value="Public Transportation">
|
|
Public
|
|
Transportation
|
|
</option>
|
|
<option value="Blessed Assurance">
|
|
Blessed
|
|
Assurance
|
|
</option>
|
|
</select>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="int"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="arrive_time">
|
|
<span class="s_website_form_label_content">
|
|
Arrive Time:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="arrive_time"
|
|
type="number"
|
|
class="form-control s_website_form_input"
|
|
name="arrive_time"
|
|
min="0"
|
|
max="24"/>
|
|
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="int"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="departure_time">
|
|
<span class="s_website_form_label_content">
|
|
Departure Time:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="departure_time"
|
|
type="number"
|
|
class="form-control s_website_form_input"
|
|
name="departure_time"
|
|
min="0"
|
|
max="24"/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="date"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="yes">
|
|
<span class="s_website_form_label_content">
|
|
Special Diet?:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input type="radio"
|
|
id="Yes"
|
|
name="diet"
|
|
value="Yes"
|
|
required=""/>
|
|
<label for="Yes">
|
|
Yes
|
|
</label>
|
|
<input type="radio"
|
|
id="No"
|
|
name="diet"
|
|
value="No"/>
|
|
<label for="No">No
|
|
</label>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="char"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="diet_detail">
|
|
<span class="s_website_form_label_content">
|
|
If yes, give
|
|
details:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="diet_detail"
|
|
type="text"
|
|
class="form-control s_website_form_input"
|
|
name="diet_detail"/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="char"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="allergies">
|
|
<span class="s_website_form_label_content">
|
|
List all
|
|
allergies:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="allergies"
|
|
type="text"
|
|
class="form-control s_website_form_input"
|
|
name="allergies"/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="char"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="request_assurance">
|
|
<span class="s_website_form_label_content">
|
|
Days and times
|
|
requested to be
|
|
at Blessed
|
|
Assurance:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="request_assurance"
|
|
type="text"
|
|
class="form-control s_website_form_input"
|
|
name="request_assurance"/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="char"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="paid_by">
|
|
<span class="s_website_form_label_content">
|
|
I acknowledge
|
|
that the
|
|
participation in
|
|
this program
|
|
will be paid by
|
|
:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<select id="paid_by"
|
|
class="form-control s_website_form_input"
|
|
name="paid_by">
|
|
<option value="Myself">
|
|
Myself
|
|
</option>
|
|
<option value="Relative">
|
|
Relative
|
|
</option>
|
|
<option value="Another Party">
|
|
Another
|
|
Party
|
|
</option>
|
|
</select>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="char"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="paid_by_name">
|
|
<span class="s_website_form_label_content">
|
|
Give name of
|
|
person/party
|
|
responsible that
|
|
is mentioned
|
|
above:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="paid_by_name"
|
|
type="text"
|
|
class="form-control s_website_form_input"
|
|
name="paid_by_name"
|
|
required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="char"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="paid_by_phone">
|
|
<span class="s_website_form_label_content">
|
|
Phone number of
|
|
person to pay
|
|
bill:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="paid_by_phone"
|
|
type="text"
|
|
class="form-control s_website_form_input"
|
|
name="paid_by_phone"
|
|
required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="char"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="email">
|
|
<span class="s_website_form_label_content">
|
|
Your Email:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="email"
|
|
type="email"
|
|
class="form-control s_website_form_input"
|
|
name="email"
|
|
required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="char"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="hospital_choice">
|
|
<span class="s_website_form_label_content">
|
|
If emergency
|
|
medical care
|
|
becomes
|
|
necessary, I
|
|
give permission
|
|
for any
|
|
treatment the
|
|
physician deems
|
|
necessary. My
|
|
hospital choice
|
|
is:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="hospital_choice"
|
|
type="text"
|
|
class="form-control s_website_form_input"
|
|
name="hospital_choice"
|
|
placeholder="e.g.City Life Hospital"/>
|
|
<span>But I (the
|
|
applicant) may
|
|
be treated at
|
|
the nearest
|
|
facility if the
|
|
emergency deems
|
|
it necessary.
|
|
</span>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_field s_website_form_custom s_website_form_required"
|
|
data-type="char"
|
|
data-name="Field">
|
|
<div class="row s_col_no_resize s_col_no_bgcolor">
|
|
<label class="col-form-label col-sm-auto s_website_form_label"
|
|
style="width: 200px"
|
|
for="digital_sign">
|
|
<span class="s_website_form_label_content">
|
|
By entering your
|
|
full name, you
|
|
are digitally
|
|
signing this
|
|
form:
|
|
</span>
|
|
</label>
|
|
<div class="col-sm">
|
|
<input id="digital_sign"
|
|
type="text"
|
|
class="form-control s_website_form_input"
|
|
name="digital_sign"
|
|
required=""/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="mb-0 py-2 col-12 s_website_form_submit"
|
|
data-name="Submit Button">
|
|
<div style="width: 200px;"
|
|
class="s_website_form_label"/>
|
|
<button type="submit"
|
|
class="btn btn-primary">
|
|
Submit
|
|
</button>
|
|
</div>
|
|
</div>
|
|
</form>
|
|
</div>
|
|
</section>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</section>
|
|
</div>
|
|
</t>
|
|
</template>
|
|
<template id="assessment_request_submit_template"
|
|
name="Assessment Request Submitted">
|
|
<!-- Template assessment request submit in website-->
|
|
<t t-call="website.layout">
|
|
<div id="wrap" class="oe_structure oe_empty">
|
|
<section
|
|
class="s_title parallax s_parallax_is_fixed bg-black-50 pt24 pb24"
|
|
data-vcss="001" data-snippet="s_title"
|
|
data-scroll-background-ratio="1">
|
|
<span class="s_parallax_bg oe_img_bg"
|
|
style="background-image: url('/web/image/website.s_banner_default_image'); background-position: 50% 0;"/>
|
|
<div class="o_we_bg_filter bg-black-50"/>
|
|
<div class="container">
|
|
<h1>Assessment Request Form</h1>
|
|
</div>
|
|
</section>
|
|
<section class="s_website_form" data-vcss="001"
|
|
data-snippet="s_website_form">
|
|
<div class="container s_allow_columns">
|
|
<div class="row">
|
|
<div class="col-lg-8 mt-4 mt-lg-0">
|
|
<div class="alert alert-success">
|
|
Your Day Care Assessment Request is "<t
|
|
t-esc="lead['name']"/>".
|
|
<br/>
|
|
Please Note it for further communication.
|
|
<br/>
|
|
You Will Receive Email from our Team
|
|
shortly.
|
|
<br/>
|
|
Please reply to that mail for feature
|
|
conversation.
|
|
<br/>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</section>
|
|
</div>
|
|
</t>
|
|
</template>
|
|
</odoo>
|
|
|