1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149<!doctype html>
<html lang="en">
<head>
<!-- Required meta tags -->
<meta charset="utf-8">
<meta name="viewport" content="width=device-width, initial-scale=1, shrink-to-fit=no">
<!--CSS -->
<link href="https://fonts.googleapis.com/css2?family=Roboto:ital,wght@0,100;0,300;0,400;0,500;0,700;0,900;1,100;1,300;1,400;1,500;1,700;1,900&display=swap" rel="stylesheet">
<link rel="stylesheet" href="{{ url_for('static', filename='css/bootstrap.css') }}">
<link rel="stylesheet" href="{{ url_for('static', filename='css/style.css') }}">
<script src="//ajax.googleapis.com/ajax/libs/jquery/2.1.4/jquery.min.js"></script>
<script src="https://cdn.jsdelivr.net/npm/sweetalert2@9"></script>
<title>Exact Science</title>
</head>
<body>
<div class="main-wrap">
<!-- Wrap -->
<div class="wraper">
<div class="container-fluid">
<div class="row">
<div class="right-panel-box col-12 col-md-10 col-sm-12" id="right" style="height: auto; padding-left: 15px; margin:auto; margin-top: 15px;">
<img src="{{ url_for('static', filename='images/logo.png') }}" style="height: auto; width: 10%; position: absolute;">
<img src="{{ url_for('static', filename='images/colo.jpeg') }}" style="height: auto; width: 10%; position: absolute; right: 15px; top: 5px;">
<center>
<h3>COLOGUARD PROCEDURE<br>INFORMATION </h3>
</center>
<form class="update2" id="update2" action="/update2" method="post">
<h3>
Information from Cologuard Provider
</h3>
<div class="form-field-wrap input-group">
<label class="">Cologuard Order Number :</label>
<input class="input-group-append form-control" type="text" name="colo_number2" value="{{dict1['form2']['colo_number2']}}" />
</div>
<div class="form-field-wrap input-group">
<label class="">Date Received by ES Labs :</label>
<input class="input-group-append form-control" type="text" name="es_date2" value="{{dict1['form2']['es_date2']}}"/>
</div>
<div class="form-field-wrap input-group">
<label class="">Health Organization Name :</label>
<input class="input-group-append form-control" type="text" name="hco_name2" value="{{dict1['form2']['hco_name2']}}"/>
</div>
<div class="form-field-wrap input-group">
<label class="">Provider Name :</label>
<input class="input-group-append form-control" type="text" name="pr_name2" value="{{dict1['form2']['pr_name2']}}"/>
</div>
<div class="form-field-wrap input-group">
<label class="">Provider NPI # :</label>
<input class="input-group-append form-control" type="text" name="pr_npi2" value="{{dict1['form2']['pr_npi2']}}"/>
</div>
<div class="form-field-wrap input-group">
<label class="">ICD-10 Code :</label>
<input class="input-group-append form-control" type="text" name="icd_code2" value="{{dict1['form2']['icd_code2']}}"/>
</div>
<div class="form-field-wrap input-group">
<label class="">Patient Name :</label>
<input class="input-group-append form-control" type="text" name="pt_name2" value="{{dict1['form2']['pt_name2']}}"/>
</div>
<div class="form-field-wrap input-group">
<label class="">Patient Date of Birth :</label>
<input class="input-group-append form-control" type="text" name="pt_dob2" value="{{dict1['form2']['pt_dob2']}}"/>
</div>
<div class="form-field-wrap input-group">
<label class="">Patient Sex :</label>
<input class="input-group-append form-control" type="text" name="pt_sex2" value="{{dict1['form2']['pt_sex2']}}"/>
</div>
<div class="form-field-wrap input-group">
<label class="">Patient Phone Number :</label>
<input class="input-group-append form-control" type="text" name="pt_phone2" value="{{dict1['form2']['pt_phone2']}}"/>
</div>
<div class="form-field-wrap input-group">
<label class="">Patient Shipping Address :</label>
<input class="input-group-append form-control" type="text" name="pt_saddress2" value="{{dict1['form2']['pt_saddress2']}}"/>
</div>
<div class="form-field-wrap input-group">
<label class="">Secure Fax Number :</label>
<input class="input-group-append form-control" type="text" name="pt_fax2" value="{{dict1['form2']['pt_fax2']}}"/>
</div>
<div class="form-field-wrap input-group">
<label class="">Health Care Provider Signature :</label>
<input class="input-group-append form-control" type="text" name="hcp_sign2" value="{{dict1['form2']['hcp_sign2']}}"/>
</div>
<div class="form-field-wrap input-group">
<label class="">Insurance Type :</label>
<input class="input-group-append form-control" type="text" name="insurance_type2" value="{{dict1['form2']['insurance_type2']}}"/>
</div>
<div class="form-field-wrap input-group">
<label class="">Insurance Carrier Name :</label>
<input class="input-group-append form-control" type="text" name="insurance_carrier2" value="{{dict1['form2']['insurance_carrier2']}}"/>
</div>
<div class="form-field-wrap input-group">
<label class="">Subscriber ID :</label>
<input class="input-group-append form-control" type="text" name="sub_id2" value="{{dict1['form2']['sub_id2']}}"/>
</div>
<div class="form-field-wrap input-group">
<label class="">Group Number :</label>
<input class="input-group-append form-control" type="text" name="group_number2" value="{{dict1['form2']['group_number2']}}"/>
</div>
<div class="form-field-wrap input-group">
<label class="">Policy Owner/Holder Name :</label>
<input class="input-group-append form-control" type="text" name="poly_name2" value="{{dict1['form2']['poly_name2']}}"/>
</div>
<div class="form-field-wrap input-group">
<label class="">Policy Owner/Holder Date of Birth :</label>
<input class="input-group-append form-control" type="text" name="poly_dob2" value="{{dict1['form2']['poly_dob2']}}"/>
</div>
</form>
<!-- Savan Code End -->
<div class="input-group mb-0 d-inline" style="width: auto; margin:auto; margin-top:20px; ">
<input class="mr-1" form="update2" type="checkbox" id="isallextracted" name="isallextracted" value="Yes">
<label class="mb-2" for="isallextracted">Please mark right only if all data extracted are as same as hard copy for both form.</label>
</div>
<input type="submit" name="Submit" value="SUBMIT" class="btn btn-dark" style="margin: auto; margin-top:10px;margin-bottom: 10px; width:200px ; height:auto; font-size:25px; float: right;" onclick="submitForms()">
</div>
</div>
</div>
</div>
</div>
<!--JavaScript -->
<script src="static\js\jquery-3.5.1.slim.min.js" type="text/javascript"></script>
<script src="static\js\popper.min.js" type="text/javascript"></script>
<script src="static\js\bootstrap.js" type="text/javascript"></script>
<script src="static\js\app.js" type="text/javascript"></script>
</body>
<script type="text/javascript">
submitForms = function(){
Swal.fire({position: 'center',
icon: 'success',
title: 'Information has been updated',
showConfirmButton: false,
timer: 3000
})
setTimeout(function(){ document.getElementById("update2").submit(); }, 2000);
}
</script>
</html>