PHC Geriatric Clinic Referral eForm

Created by Dr. Patyal. An eForm for referral to the Providence Health Care - Elder Care Geriatric Outpatient Clinic.
<!-- Updated 2019-Nov-23
Moved second page to the side - do not print - to save ink and paper
Updated Code for X boxes
Added Radio X boxes
Converted 2 "other" inputs to 1 text area
Photoshopped out boxes and some lines on image
added with text to clarify some inputs
corrected DOB to conform with requested format
Parsed Referring Physician Name
Pre-Checked some boxes on initial opening
Added some cosmetics
-->