Your Smile Partners PLLC \u2014 Teledentistry Prescription Refill Request Form<\/title> <meta name=\"viewport\" content=\"width=device-width,initial-scale=1\" \/> <link rel=\"preconnect\" href=\"https:\/\/fonts.googleapis.com\" crossorigin> <link rel=\"preconnect\" href=\"https:\/\/fonts.gstatic.com\" crossorigin> <link href=\"https:\/\/fonts.googleapis.com\/css2?family=Roboto:wght@300;400;500;700;900&display=swap\" rel=\"stylesheet\"> <style> :root{ --bg: #f6faff; --card: #ffffff; --ink: #18223b; --muted: #5c6e8d; --line: #e4ecfb; --accent-1: #4c8fff; --accent-2: #2bd0d6; --accent-3: #6d7cff; --ok: #12a66a; --warn: #f59f00; --field-bg: #ffffff; --field-border: #d6e2fb; --shadow-1: 0 10px 30px rgba(35, 66, 153, 0.10); --r: 16px; --r-sm: 12px; } *,*::before,*::after{ box-sizing:border-box; } html,body{ margin:0; padding:0; } body{ font-family: 'Roboto', system-ui, -apple-system, Segoe UI, Roboto, \"Helvetica Neue\", Arial, \"Apple Color Emoji\",\"Segoe UI Emoji\"; color: var(--ink); background: radial-gradient(900px 400px at 0% -10%, rgba(76,143,255,0.12), transparent 60%), radial-gradient(900px 420px at 100% 0%, rgba(43,208,214,0.10), transparent 60%), var(--bg); 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}\r\n body{ background:#fff; }\r\n .card{ box-shadow:none; border:none; }\r\n .section{ page-break-inside: avoid; }\r\n}\r\n<\/style> <\/head> <body> <main class=\"wrap\" role=\"main\"> <section class=\"card\" id=\"form-card\" aria-labelledby=\"title\"> <div class=\"edge\" aria-hidden=\"true\"><\/div>\r\n <header class=\"app\">\r\n <div class=\"logo\" aria-hidden=\"true\">\r\n <svg viewBox=\"0 0 64 64\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" aria-hidden=\"true\">\r\n <defs>\r\n <linearGradient id=\"g\" x1=\"0\" y1=\"0\" x2=\"1\" y2=\"1\">\r\n <stop stop-color=\"#4C8FFF\"\/><stop offset=\"1\" stop-color=\"#2BD0D6\"\/>\r\n <\/linearGradient>\r\n <\/defs>\r\n <path d=\"M32 4l20 8v14c0 14-9.6 26.8-20 30C21.6 52.8 12 40 12 26V12l20-8z\" stroke=\"url(#g)\" stroke-width=\"2.2\" fill=\"#eaf3ff\"\/>\r\n <path d=\"M22 31.5l7 7L44 24\" stroke=\"#4C8FFF\" stroke-width=\"3\" stroke-linecap=\"round\" stroke-linejoin=\"round\"\/>\r\n <\/svg>\r\n <\/div>\r\n <h1 class=\"title\" id=\"title\">Teledentistry Prescription Refill Request Form<\/h1>\r\n <div class=\"meta\">\r\n <span class=\"pill\"><strong>Your Smile Partners PLLC<\/strong><\/span>\r\n <span class=\"pill\">99 Wall St, New York, NY 10005<\/span>\r\n <span class=\"pill\">Email: <a href=\"mailto:talk@yoursmilepartners.com\">talk@yoursmilepartners.com<\/a><\/span>\r\n <span class=\"pill\">Phone: (212) 555\u2011SMILE<\/span>\r\n <\/div>\r\n <\/header>\r\n <div class=\"toolbar\" role=\"toolbar\" aria-label=\"Form actions\">\r\n <div class=\"flow\" aria-label=\"Progress\">\r\n <span class=\"step\" id=\"st1\"><span class=\"dot\"><\/span> Step 1: Print\/Preview<\/span>\r\n <span class=\"step\" id=\"st2\"><span class=\"dot\"><\/span> Step 2: Save PDF<\/span>\r\n <span class=\"step\" id=\"st3\"><span class=\"dot\"><\/span> Step 3: Submit & Upload<\/span>\r\n <\/div>\r\n <div style=\"flex:1\"><\/div>\r\n <button type=\"button\" class=\"btn\" id=\"btnPrint\">Print \/ Preview<\/button>\r\n <button type=\"button\" class=\"btn primary\" id=\"btnSave\" disabled>Save PDF to Device<\/button>\r\n <button type=\"button\" class=\"btn ok\" id=\"btnSubmit\" disabled>Submit & Upload to Dropbox<\/button>\r\n <button type=\"button\" class=\"btn warn\" id=\"btnClear\">Clear All Fields<\/button>\r\n <\/div>\r\n <form id=\"refill-form\" novalidate>\r\n <div class=\"section\">\r\n <p>Please complete this form in full to request a prescription refill. Your responses help us ensure safe and appropriate medication management.<\/p>\r\n <\/div>\r\n \r\n <div class=\"section\">\r\n <h3>1. Patient Information<\/h3>\r\n <div class=\"grid cols-3\">\r\n <div style=\"grid-column: span 2;\">\r\n <label for=\"fullName\">Full Name<\/label>\r\n <div class=\"field\"><input id=\"fullName\" name=\"fullName\" type=\"text\" required placeholder=\"First and last name\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"dob\">Date of Birth<\/label>\r\n <div class=\"field\"><input id=\"dob\" name=\"dob\" type=\"date\" required \/><\/div>\r\n <\/div>\r\n <div style=\"grid-column:1\/-1\">\r\n <label for=\"address\">Address<\/label>\r\n <div class=\"field\"><input id=\"address\" name=\"address\" type=\"text\" required placeholder=\"Street address\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"city\">City<\/label>\r\n <div class=\"field\"><input id=\"city\" name=\"city\" type=\"text\" required \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"state\">State<\/label>\r\n <div class=\"field\"><input id=\"state\" name=\"state\" type=\"text\" required maxlength=\"2\" placeholder=\"NY\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"zip\">ZIP<\/label>\r\n <div class=\"field\"><input id=\"zip\" name=\"zip\" type=\"text\" required pattern=\"\\\\d{5}(-\\\\d{4})?\" placeholder=\"10005\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"phone\">Phone<\/label>\r\n <div class=\"field\"><input id=\"phone\" name=\"phone\" type=\"tel\" required placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div>\r\n <div class=\"options\" style=\"margin-top:6px;\">\r\n <span style=\"font-weight:600;color:#1e315c;\">Preferred Contact<\/span>\r\n <label class=\"opt\"><input type=\"radio\" name=\"prefContact\" value=\"Phone\" required \/> Phone<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"prefContact\" value=\"SMS\" \/> SMS<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"prefContact\" value=\"Email\" \/> Email<\/label>\r\n <\/div>\r\n <\/div>\r\n <div style=\"grid-column: span 2;\">\r\n <label for=\"email\">Email Address<\/label>\r\n <div class=\"field\"><input id=\"email\" name=\"email\" type=\"email\" required placeholder=\"you@example.com\" \/><\/div>\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n \r\n <div class=\"section\">\r\n <h3>2. Prescription Information<\/h3>\r\n <div class=\"grid cols-3\">\r\n <div style=\"grid-column:1\/-1\">\r\n <label for=\"medName\">Medication Name<\/label>\r\n <div class=\"field\"><input id=\"medName\" name=\"medName\" type=\"text\" required \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"strength\">Strength (e.g., 500 mg)<\/label>\r\n <div class=\"field\"><input id=\"strength\" name=\"strength\" type=\"text\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"formMed\">Form (e.g., tablet, gel, rinse)<\/label>\r\n <div class=\"field\"><input id=\"formMed\" name=\"formMed\" type=\"text\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"dosage\">Current Dosage & Frequency<\/label>\r\n <div class=\"field\"><input id=\"dosage\" name=\"dosage\" type=\"text\" required placeholder=\"e.g., 1 tab twice daily\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"origDate\">Original Prescription Date<\/label>\r\n <div class=\"field\"><input id=\"origDate\" name=\"origDate\" type=\"date\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"rxNumber\">Prescription Number (if known)<\/label>\r\n <div class=\"field\"><input id=\"rxNumber\" name=\"rxNumber\" type=\"text\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"pharmacy\">Pharmacy Name<\/label>\r\n <div class=\"field\"><input id=\"pharmacy\" name=\"pharmacy\" type=\"text\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"pharmacyPhone\">Pharmacy Phone<\/label>\r\n <div class=\"field\"><input id=\"pharmacyPhone\" name=\"pharmacyPhone\" type=\"tel\" placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div>\r\n <\/div>\r\n <\/div>\r\n <div style=\"margin-top:10px;\">\r\n <label for=\"refillReason\">Reason for Refill Request<\/label>\r\n <div class=\"field\"><textarea id=\"refillReason\" name=\"refillReason\"><\/textarea><\/div>\r\n <\/div>\r\n <\/div>\r\n \r\n <div class=\"section\">\r\n <h3>3. Symptom & Oral Health Screening<\/h3>\r\n <p>Are you currently experiencing any of the following? (Check all that apply)<\/p>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"sym\" value=\"New or worsening pain\" \/> New or worsening pain at treatment site<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"sym\" value=\"Swelling\" \/> Swelling of gums, face, or jaw<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"sym\" value=\"Bleeding\" \/> Bleeding from gums or oral tissues<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"sym\" value=\"Ulcers\/sores\/lesions\" \/> Ulcers, sores, or lesions in mouth<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"sym\" value=\"Sensitivity\" \/> Increased sensitivity to hot\/cold\/sweet<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"sym\" value=\"Dry mouth\" \/> Dry mouth or excessive salivation<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"sym\" value=\"Dysphagia\" \/> Difficulty swallowing or speaking<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"sym\" value=\"Other\" \/> Other<\/label>\r\n <\/div>\r\n <div class=\"field\" style=\"margin-top:8px;\"><input id=\"symOther\" name=\"symOther\" type=\"text\" placeholder=\"If Other, specify\" \/><\/div>\r\n <div style=\"margin-top:10px;\">\r\n <label>Symptom severity (0 = none; 10 = worst)<\/label>\r\n <div class=\"range-wrap\">\r\n <span>0<\/span>\r\n <input id=\"severity\" type=\"range\" min=\"0\" max=\"10\" step=\"1\" value=\"0\" oninput=\"document.getElementById('severityOut').value=this.value\" \/>\r\n <span>10<\/span>\r\n <output id=\"severityOut\">0<\/output>\r\n <\/div>\r\n <\/div>\r\n <div class=\"grid cols-2\" style=\"margin-top:10px;\">\r\n <div>\r\n <label>New medications\/supplements since last visit?<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"newMeds\" value=\"Yes\" \/> Yes<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"newMeds\" value=\"No\" \/> No<\/label>\r\n <\/div>\r\n <div class=\"field\" style=\"margin-top:8px;\"><input id=\"newMedsList\" name=\"newMedsList\" type=\"text\" placeholder=\"If Yes, list names and dosages\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label>Known allergies or adverse reactions?<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"allergy\" value=\"Yes\" \/> Yes<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"allergy\" value=\"No\" \/> No<\/label>\r\n <\/div>\r\n <div class=\"field\" style=\"margin-top:8px;\"><input id=\"allergyDesc\" name=\"allergyDesc\" type=\"text\" placeholder=\"If Yes, specify\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label>New medical condition since last visit?<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"newCondition\" value=\"Yes\" \/> Yes<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"newCondition\" value=\"No\" \/> No<\/label>\r\n <\/div>\r\n <div class=\"field\" style=\"margin-top:8px;\"><input id=\"newConditionDesc\" name=\"newConditionDesc\" type=\"text\" placeholder=\"If Yes, describe\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label>Currently pregnant or breastfeeding?<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"pregBF\" value=\"Yes\" \/> Yes<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"pregBF\" value=\"No\" \/> No<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"pregBF\" value=\"N\/A\" \/> N\/A<\/label>\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n \r\n <div class=\"section\">\r\n <h3>4. Medication Use & Compliance<\/h3>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"adherence\" value=\"Yes\" \/> I have been taking medication as directed<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"adherence\" value=\"No\" \/> No<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"adherence\" value=\"Sometimes\" \/> Sometimes<\/label>\r\n <\/div>\r\n <div class=\"field\" style=\"margin-top:8px;\"><input id=\"adherenceExplain\" name=\"adherenceExplain\" type=\"text\" placeholder=\"If No\/Sometimes, please explain\" \/><\/div>\r\n <p style=\"margin-top:10px;\">Side effects experienced (check all that apply)<\/p>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"side\" value=\"Nausea\" \/> Nausea or vomiting<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"side\" value=\"Dizziness\" \/> Dizziness or lightheadedness<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"side\" value=\"Rash\" \/> Rash or itching<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"side\" value=\"GI upset\" \/> Gastrointestinal upset<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"side\" value=\"Headache\" \/> Headache<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"side\" value=\"Other\" \/> Other<\/label>\r\n <\/div>\r\n <div class=\"field\" style=\"margin-top:8px;\"><textarea id=\"sideDetails\" name=\"sideDetails\" placeholder=\"If checked, describe severity and duration\"><\/textarea><\/div>\r\n <div style=\"margin-top:10px;\">\r\n <label>Do you have enough medication to last until the refill is processed?<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"enoughMed\" value=\"Yes\" \/> Yes<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"enoughMed\" value=\"No\" \/> No<\/label>\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n \r\n <div class=\"section\">\r\n <h3>5. Follow\u2011Up & Care Plan<\/h3>\r\n <div class=\"grid cols-2\">\r\n <div>\r\n <label>Do you require a telehealth consultation before approval?<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"needConsult\" value=\"Yes\" \/> Yes<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"needConsult\" value=\"No\" \/> No<\/label>\r\n <\/div>\r\n <\/div>\r\n <div>\r\n <label>Schedule a follow\u2011up teledentistry appointment?<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"followUp\" value=\"Yes\" \/> Yes<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"followUp\" value=\"No\" \/> No<\/label>\r\n <\/div>\r\n <div class=\"options\" style=\"margin-top:8px;\">\r\n <span style=\"font-weight:600;color:#1e315c;\">Preferred time<\/span>\r\n <label class=\"opt\"><input type=\"radio\" name=\"prefTime\" value=\"Morning\" \/> Morning<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"prefTime\" value=\"Afternoon\" \/> Afternoon<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"prefTime\" value=\"Evening\" \/> Evening<\/label>\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n <div style=\"margin-top:10px;\">\r\n <label for=\"questions\">Questions or concerns about medication or treatment plan<\/label>\r\n <div class=\"field\"><textarea id=\"questions\" name=\"questions\"><\/textarea><\/div>\r\n <\/div>\r\n <\/div>\r\n \r\n <div class=\"section\">\r\n <h3>6. Authorization & Signature<\/h3>\r\n <ul class=\"note\" style=\"padding-left:18px; margin:8px 0;\">\r\n <li>The practice will review my request and may contact me for further assessment.<\/li>\r\n <li>Approval of a refill request is at the discretion of the prescribing provider.<\/li>\r\n <li>If clinical evaluation is required, I may be asked to schedule a virtual or in\u2011office visit.<\/li>\r\n <\/ul>\r\n <div class=\"options\" style=\"margin:10px 0;\">\r\n <label class=\"opt\"><input type=\"checkbox\" id=\"consentAck\" required \/> I certify the information is accurate and complete.<\/label>\r\n <\/div>\r\n <div class=\"grid cols-2\">\r\n <div>\r\n <label>Patient Signature<\/label>\r\n <div class=\"sig-pad\">\r\n <canvas class=\"signature\" id=\"sigPatient\" aria-label=\"Patient signature\"><\/canvas>\r\n <div class=\"sig-tools\"><button type=\"button\" class=\"btn\" data-clear=\"sigPatient\">Clear<\/button><\/div>\r\n <\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"sigDate\">Date<\/label>\r\n <div class=\"field\"><input id=\"sigDate\" name=\"sigDate\" type=\"date\" required \/><\/div>\r\n <\/div>\r\n <\/div>\r\n <h3 style=\"margin-top:14px;\">If signed by guardian\/representative<\/h3>\r\n <div class=\"grid cols-2\">\r\n <div><label for=\"repName\">Name<\/label><div class=\"field\"><input id=\"repName\" name=\"repName\" type=\"text\" \/><\/div><\/div>\r\n <div><label for=\"repRel\">Relationship to Patient<\/label><div class=\"field\"><input id=\"repRel\" name=\"repRel\" type=\"text\" \/><\/div><\/div>\r\n <div>\r\n <label>Representative Signature<\/label>\r\n <div class=\"sig-pad\">\r\n <canvas class=\"signature\" id=\"sigRep\" aria-label=\"Representative signature\"><\/canvas>\r\n <div class=\"sig-tools\"><button type=\"button\" class=\"btn\" data-clear=\"sigRep\">Clear<\/button><\/div>\r\n <\/div>\r\n <\/div>\r\n <div><label for=\"repDate\">Date<\/label><div class=\"field\"><input id=\"repDate\" name=\"repDate\" type=\"date\" \/><\/div><\/div>\r\n <\/div>\r\n <\/div>\r\n <div class=\"section\">\r\n <p class=\"note\"><strong>Thank you for your request.<\/strong> We aim to process refill requests within 2 business days.<\/p>\r\n <\/div>\r\n <\/form>\r\n <div class=\"footer\">\r\n <div class=\"note\">Workflow: Print\/Preview your completed form \u2192 Save a PDF copy \u2192 Submit & upload to our secure Dropbox.<\/div>\r\n <div style=\"display:flex; gap:10px;\">\r\n <button type=\"button\" class=\"btn\" id=\"btnPrint2\">Print \/ Preview<\/button>\r\n <button type=\"button\" class=\"btn primary\" id=\"btnSave2\" disabled>Save PDF<\/button>\r\n <button type=\"button\" class=\"btn ok\" id=\"btnSubmit2\" disabled>Submit & Upload<\/button>\r\n <\/div>\r\n <\/div>\r\n<\/section>\r\n<\/main> <div class=\"toast\" id=\"toast\" role=\"status\" aria-live=\"polite\" aria-atomic=\"true\">Ready<\/div> <script src=\"https:\/\/cdn.jsdelivr.net\/npm\/html2pdf.js@0.10.1\/dist\/html2pdf.bundle.min.js\" crossorigin=\"anonymous\"><\/script> <script> (function(){ const dropboxURL = 'https:\/\/www.dropbox.com\/request\/gdRmWuwrMys3cW8R8Xua'; const form = document.getElementById('refill-form'); const card = document.getElementById('form-card'); const toast = document.getElementById('toast');\r\n const btnPrint = document.getElementById('btnPrint');\r\n const btnPrint2 = document.getElementById('btnPrint2');\r\n const btnSave = document.getElementById('btnSave');\r\n const btnSave2 = document.getElementById('btnSave2');\r\n const btnSubmit = document.getElementById('btnSubmit');\r\n const btnSubmit2 = document.getElementById('btnSubmit2');\r\n const btnClear = document.getElementById('btnClear');\r\n const st1 = document.getElementById('st1');\r\n const st2 = document.getElementById('st2');\r\n const st3 = document.getElementById('st3');\r\n \/\/ Signature pads\r\n const pads = {\r\n sigPatient: setupSignaturePad(document.getElementById('sigPatient')),\r\n sigRep: setupSignaturePad(document.getElementById('sigRep'))\r\n };\r\n document.querySelectorAll('[data-clear]').forEach(btn=>{\r\n btn.addEventListener('click', ()=>{\r\n const id = btn.getAttribute('data-clear');\r\n pads[id]?.clear();\r\n });\r\n });\r\n \/\/ Defaults\r\n const todayISO = (new Date()).toISOString().slice(0,10);\r\n const defaultDateIds = ['sigDate'];\r\n defaultDateIds.forEach(id => { const el = document.getElementById(id); if(el && !el.value) el.value = todayISO; });\r\n \/\/ State\r\n let hasPrinted = false;\r\n let hasSaved = false;\r\n function setSaveEnabled(on){ btnSave.disabled = !on; btnSave2.disabled = !on; }\r\n function setSubmitEnabled(on){ btnSubmit.disabled = !on; btnSubmit2.disabled = !on; }\r\n function updateSteps(){\r\n st1.classList.toggle('done', hasPrinted);\r\n st2.classList.toggle('done', hasSaved);\r\n st3.classList.toggle('done', hasSaved);\r\n setSaveEnabled(hasPrinted); \/\/ Save allowed only after print\/preview\r\n setSubmitEnabled(hasSaved); \/\/ Submit allowed only after save\r\n }\r\n updateSteps();\r\n \/\/ Toast helper\r\n let tmr;\r\n function showToast(msg){\r\n toast.textContent = msg;\r\n toast.classList.add('show');\r\n clearTimeout(tmr);\r\n tmr = setTimeout(()=> toast.classList.remove('show'), 1800);\r\n }\r\n \/\/ Validation\r\n function validateForm(){\r\n const reqIds = ['fullName','dob','address','city','state','zip','phone','email','medName','dosage','sigDate'];\r\n for(const id of reqIds){\r\n const el = document.getElementById(id);\r\n if(!el || (el.value || '').trim() === ''){\r\n el?.scrollIntoView({behavior:'smooth', block:'center'});\r\n el?.focus?.({preventScroll:true});\r\n showToast('Please complete required fields.');\r\n return false;\r\n }\r\n }\r\n if(!form.querySelector('input[name=\"prefContact\"]:checked')){\r\n showToast('Please select a preferred contact method.');\r\n form.querySelector('input[name=\"prefContact\"]')?.scrollIntoView({behavior:'smooth', block:'center'});\r\n return false;\r\n }\r\n const consent = document.getElementById('consentAck');\r\n if(!consent.checked){\r\n consent.scrollIntoView({behavior:'smooth', block:'center'});\r\n showToast('Please confirm the authorization.');\r\n return false;\r\n }\r\n if(pads.sigPatient.isBlank()){\r\n document.getElementById('sigPatient').scrollIntoView({behavior:'smooth', block:'center'});\r\n showToast('Please add your signature.');\r\n return false;\r\n }\r\n return true;\r\n }\r\n \/\/ Print\/Preview\r\n function doPrint(){\r\n if(!validateForm()) return;\r\n window.print();\r\n }\r\n btnPrint.addEventListener('click', doPrint);\r\n btnPrint2.addEventListener('click', doPrint);\r\n \/\/ Detect when print preview closes\r\n function afterPrint(){\r\n hasPrinted = true;\r\n updateSteps();\r\n showToast('Print preview closed. You can now save a PDF.');\r\n }\r\n if('onafterprint' in window){\r\n window.addEventListener('afterprint', afterPrint);\r\n }else{\r\n btnPrint.addEventListener('click', ()=> setTimeout(afterPrint, 3000));\r\n btnPrint2.addEventListener('click', ()=> setTimeout(afterPrint, 3000));\r\n }\r\n \/\/ Filename for PDF\r\n function makeFileName(){\r\n const name = (document.getElementById('fullName').value || 'Patient').trim().replace(\/\\s+\/g,'_');\r\n const date = (document.getElementById('sigDate').value || todayISO);\r\n return `Rx_Refill_Request_${name}_${date}.pdf`;\r\n }\r\n \/\/ Save PDF (html2pdf)\r\n async function savePDF(){\r\n if(!hasPrinted){\r\n showToast('Please print\/preview first.');\r\n return;\r\n }\r\n if(!validateForm()) return;\r\n await ensureSignatures();\r\n const opt = {\r\n margin: 0.4,\r\n filename: makeFileName(),\r\n image: { type: 'jpeg', quality: 0.98 },\r\n html2canvas: { scale: 2, useCORS: true, backgroundColor: '#ffffff' },\r\n jsPDF: { unit: 'in', format: 'letter', orientation: 'portrait' },\r\n pagebreak: { mode: ['css','legacy'] }\r\n };\r\n await html2pdf().from(card).set(opt).save();\r\n hasSaved = true;\r\n updateSteps();\r\n showToast('PDF saved to your device.');\r\n }\r\n btnSave.addEventListener('click', savePDF);\r\n btnSave2.addEventListener('click', savePDF);\r\n \/\/ Submit & Upload to Dropbox (redirect)\r\n async function submitAndUpload(){\r\n if(!hasSaved){\r\n showToast('Please save a PDF first.');\r\n return;\r\n }\r\n if(!validateForm()) return;\r\n try{\r\n const win = window.open(dropboxURL, '_blank');\r\n win?.focus();\r\n }catch(e){\r\n window.location.href = dropboxURL;\r\n }\r\n }\r\n btnSubmit.addEventListener('click', submitAndUpload);\r\n btnSubmit2.addEventListener('click', submitAndUpload);\r\n \/\/ Clear\r\n btnClear.addEventListener('click', ()=>{\r\n if(!confirm('Clear all fields and signatures?')) return;\r\n form.reset();\r\n defaultDateIds.forEach(id => { const el = document.getElementById(id); if(el) el.value = todayISO; });\r\n pads.sigPatient.clear();\r\n pads.sigRep.clear();\r\n hasPrinted = false; hasSaved = false;\r\n updateSteps();\r\n showToast('Form cleared.');\r\n });\r\n \/\/ Ensure signatures ready (canvas already holds strokes)\r\n async function ensureSignatures(){ return true; }\r\n \/\/ Signature pad\r\n function setupSignaturePad(canvas){\r\n const ctx = canvas.getContext('2d');\r\n const state = { drawing:false, blank:true, lastX:0, lastY:0 };\r\n function resize(){\r\n const ratio = Math.max(window.devicePixelRatio || 1, 1);\r\n const rect = canvas.getBoundingClientRect();\r\n canvas.width = rect.width * ratio;\r\n canvas.height = rect.height * ratio;\r\n ctx.setTransform(ratio, 0, 0, ratio, 0, 0);\r\n ctx.lineCap = 'round';\r\n ctx.lineJoin = 'round';\r\n ctx.lineWidth = 2.2;\r\n ctx.strokeStyle = '#18223b';\r\n ctx.clearRect(0,0,canvas.width,canvas.height);\r\n state.blank = true;\r\n }\r\n window.addEventListener('resize', resize, { passive:true });\r\n resize();\r\n function getPos(e){\r\n const r = canvas.getBoundingClientRect();\r\n const p = e.touches ? 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\n\t\t\t\t\t Your Smile Partners PLLC \u2014 Teledentistry Prescription Refill Request Form<\/title> <meta name=\"viewport\" content=\"width=device-width,initial-scale=1\" \/> <link rel=\"preconnect\" href=\"https:\/\/fonts.googleapis.com\" crossorigin> <link rel=\"preconnect\" href=\"https:\/\/fonts.gstatic.com\" crossorigin> <link href=\"https:\/\/fonts.googleapis.com\/css2?family=Roboto:wght@300;400;500;700;900&display=swap\" rel=\"stylesheet\"> <style> :root{ --bg: #f6faff; --card: #ffffff; --ink: #18223b; --muted: #5c6e8d; --line: #e4ecfb; --accent-1: #4c8fff; --accent-2: #2bd0d6; --accent-3: #6d7cff; --ok: #12a66a; --warn: #f59f00; --field-bg: #ffffff; --field-border: #d6e2fb; --shadow-1: 0 10px 30px rgba(35, 66, 153, 0.10); --r: 16px; --r-sm: 12px; } *,*::before,*::after{ box-sizing:border-box; } html,body{ margin:0; padding:0; } body{ font-family: 'Roboto', system-ui, -apple-system, Segoe UI, Roboto, \"Helvetica Neue\", Arial, \"Apple Color Emoji\",\"Segoe UI Emoji\"; color: var(--ink); 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font-size: clamp(1.15rem, 2.6vw, 1.7rem); line-height:1.25; font-weight:900; letter-spacing:.2px; }\r\n.meta{ grid-column: 1 \/ -1; display:flex; flex-wrap:wrap; gap:10px; padding-bottom:10px; color: var(--muted); font-size:.96rem; }\r\n.pill{ display:inline-flex; align-items:center; gap:8px; padding:6px 10px; border-radius:999px; background:#f1f6ff; border:1px solid var(--line); }\r\n.toolbar{\r\n display:flex; flex-wrap:wrap; gap:10px; padding: 12px 20px; border-bottom: 1px dashed var(--line);\r\n background: linear-gradient(180deg, #ffffff, #f8fbff);\r\n}\r\n.btn{\r\n appearance:none; -webkit-tap-highlight-color: transparent; user-select:none;\r\n border:1px solid #cfe0ff; background: linear-gradient(135deg, #f7fbff, #eef6ff);\r\n color: var(--ink); font-weight:700; letter-spacing:.2px; font-size:.95rem;\r\n padding:10px 14px; border-radius: 12px; cursor:pointer;\r\n transition: transform .15s ease, box-shadow .15s ease, border-color .2s ease, background .2s ease;\r\n box-shadow: 0 6px 16px rgba(76,143,255,.12);\r\n}\r\n.btn:hover{ transform: translateY(-1px); box-shadow: 0 10px 24px rgba(76,143,255,.18); }\r\n.btn:active{ transform: translateY(0); }\r\n.btn.primary{ border-color: #8dc2ff; background: linear-gradient(135deg, #e5f1ff, #e6fffb); }\r\n.btn.ok{ border-color:#a6efd6; background: linear-gradient(135deg, #eafff6, #efffff); }\r\n.btn.warn{ border-color:#ffd98a; background: linear-gradient(135deg, #fff7ea, #fffdf3); }\r\n.btn[disabled]{ opacity:.55; cursor:not-allowed; transform:none !important; box-shadow:none !important; }\r\n.flow{\r\n display:flex; gap:8px; flex-wrap:wrap; align-items:center;\r\n padding: 10px; border-radius: 12px; background:#f1f6ff; border:1px solid var(--line);\r\n font-size:.92rem; color:#1e315c;\r\n}\r\n.step{ display:inline-flex; align-items:center; gap:8px; padding:6px 10px; border-radius:999px; background:#fff; border:1px solid #dbe7ff; }\r\n.step.done{ background:#e9fff7; border-color:#bdf1df; }\r\n.dot{ width:8px;height:8px;border-radius:50%; background:#c9d9ff; }\r\n.step.done .dot{ background:#12a66a; }\r\nform#refill-form{ padding: 20px; }\r\n.section{\r\n border: 1px solid var(--line);\r\n border-radius: var(--r-sm);\r\n background: linear-gradient(180deg, #ffffff, #f9fbff);\r\n padding: 16px; margin: 16px 0;\r\n}\r\n.section h3{\r\n margin:0 0 8px 0; font-size: 1.05rem; letter-spacing:.2px; color: #1b2b55;\r\n display:flex; align-items:center; gap:10px;\r\n}\r\n.section p{ margin: 8px 0; color: var(--muted); }\r\n.grid{ display:grid; gap:12px; }\r\n@media(min-width: 780px){\r\n .grid.cols-2{ grid-template-columns: 1fr 1fr; }\r\n .grid.cols-3{ grid-template-columns: repeat(3, 1fr); }\r\n .grid.cols-4{ grid-template-columns: repeat(4, 1fr); }\r\n}\r\nlabel{ font-weight:600; font-size:.93rem; color:#1e315c; }\r\n.field{\r\n margin-top:6px; display:flex; align-items:center; gap:10px;\r\n background: var(--field-bg); border:1px solid var(--field-border); border-radius: 12px; padding: 10px 12px;\r\n transition: border-color .2s ease, box-shadow .2s ease, background .2s ease;\r\n}\r\n.field:focus-within{\r\n border-color:#9bc6ff; box-shadow: 0 0 0 4px rgba(76,143,255,.12);\r\n background:#ffffff;\r\n}\r\ninput[type=\"text\"], input[type=\"email\"], input[type=\"tel\"], input[type=\"date\"], input[type=\"time\"], input[type=\"number\"], textarea, select{\r\n width:100%; border:none; outline:none; background: transparent; color: var(--ink); font: inherit; font-size: .98rem;\r\n}\r\ntextarea{ resize: vertical; min-height: 92px; }\r\n.options{ display:flex; flex-wrap:wrap; gap:10px 18px; margin-top:8px; }\r\n.opt{ display:inline-flex; align-items:center; gap:8px; color: var(--ink); }\r\n.opt input{ transform: translateY(1px); }\r\n.range-wrap{ display:flex; align-items:center; gap:10px; margin-top:10px; }\r\n.range-wrap output{ min-width: 2ch; text-align:center; font-weight:700; color:#1b2b55; }\r\n.sig-pad{\r\n background: repeating-linear-gradient(0deg, #ffffff, #ffffff 28px, #f2f6ff 28px, #f2f6ff 29px);\r\n border: 1px dashed #c5d6fb; border-radius: 12px; padding: 10px;\r\n}\r\n.sig-tools{ display:flex; gap:10px; margin-top:8px; }\r\n.sig-tools .btn{ font-size:.88rem; padding:8px 10px; }\r\ncanvas.signature{\r\n width: 100%; height: 160px; display:block; background:#fff; border-radius: 10px; border:1px solid #e6eeff;\r\n touch-action: none;\r\n}\r\n.footer{\r\n display:flex; flex-wrap:wrap; align-items:center; justify-content:space-between; gap:12px;\r\n padding: 12px 20px 20px 20px;\r\n border-top: 1px solid var(--line);\r\n background: linear-gradient(180deg, #f9fbff, #ffffff);\r\n}\r\n.note{ color: var(--muted); font-size:.94rem; }\r\n.toast{\r\n position: fixed; left: 50%; bottom: 22px; transform: translateX(-50%) translateY(20px);\r\n background: #0f1b3a; color: #f4f8ff; border: 1px solid #2c4bff22;\r\n padding: 10px 14px; border-radius: 12px; box-shadow: var(--shadow-1);\r\n opacity: 0; transition: opacity .25s ease, transform .25s ease; pointer-events: none; z-index: 9999;\r\n font-size:.95rem;\r\n}\r\n.toast.show{ opacity: 1; transform: translateX(-50%) translateY(0); }\r\n@media print{\r\n .toolbar, .footer, .edge, .toast{ display:none !important; }\r\n body{ background:#fff; }\r\n .card{ box-shadow:none; border:none; }\r\n .section{ page-break-inside: avoid; }\r\n}\r\n<\/style> <\/head> <body> <main class=\"wrap\" role=\"main\"> <section class=\"card\" id=\"form-card\" aria-labelledby=\"title\"> <div class=\"edge\" aria-hidden=\"true\"><\/div>\r\n <header class=\"app\">\r\n <div class=\"logo\" aria-hidden=\"true\">\r\n <svg viewBox=\"0 0 64 64\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" aria-hidden=\"true\">\r\n <defs>\r\n <linearGradient id=\"g\" x1=\"0\" y1=\"0\" x2=\"1\" y2=\"1\">\r\n <stop stop-color=\"#4C8FFF\"\/><stop offset=\"1\" stop-color=\"#2BD0D6\"\/>\r\n <\/linearGradient>\r\n <\/defs>\r\n <path d=\"M32 4l20 8v14c0 14-9.6 26.8-20 30C21.6 52.8 12 40 12 26V12l20-8z\" stroke=\"url(#g)\" stroke-width=\"2.2\" fill=\"#eaf3ff\"\/>\r\n <path d=\"M22 31.5l7 7L44 24\" stroke=\"#4C8FFF\" stroke-width=\"3\" stroke-linecap=\"round\" stroke-linejoin=\"round\"\/>\r\n <\/svg>\r\n <\/div>\r\n <h1 class=\"title\" id=\"title\">Teledentistry Prescription Refill Request Form<\/h1>\r\n <div class=\"meta\">\r\n <span class=\"pill\"><strong>Your Smile Partners PLLC<\/strong><\/span>\r\n <span class=\"pill\">99 Wall St, New York, NY 10005<\/span>\r\n <span class=\"pill\">Email: <a href=\"mailto:talk@yoursmilepartners.com\">talk@yoursmilepartners.com<\/a><\/span>\r\n <span class=\"pill\">Phone: (212) 555\u2011SMILE<\/span>\r\n <\/div>\r\n <\/header>\r\n <div class=\"toolbar\" role=\"toolbar\" aria-label=\"Form actions\">\r\n <div class=\"flow\" aria-label=\"Progress\">\r\n <span class=\"step\" id=\"st1\"><span class=\"dot\"><\/span> Step 1: Print\/Preview<\/span>\r\n <span class=\"step\" id=\"st2\"><span class=\"dot\"><\/span> Step 2: Save PDF<\/span>\r\n <span class=\"step\" id=\"st3\"><span class=\"dot\"><\/span> Step 3: Submit & Upload<\/span>\r\n <\/div>\r\n <div style=\"flex:1\"><\/div>\r\n <button type=\"button\" class=\"btn\" id=\"btnPrint\">Print \/ Preview<\/button>\r\n <button type=\"button\" class=\"btn primary\" id=\"btnSave\" disabled>Save PDF to Device<\/button>\r\n <button type=\"button\" class=\"btn ok\" id=\"btnSubmit\" disabled>Submit & Upload to Dropbox<\/button>\r\n <button type=\"button\" class=\"btn warn\" id=\"btnClear\">Clear All Fields<\/button>\r\n <\/div>\r\n <form id=\"refill-form\" novalidate>\r\n <div class=\"section\">\r\n <p>Please complete this form in full to request a prescription refill. Your responses help us ensure safe and appropriate medication management.<\/p>\r\n <\/div>\r\n \r\n <div class=\"section\">\r\n <h3>1. Patient Information<\/h3>\r\n <div class=\"grid cols-3\">\r\n <div style=\"grid-column: span 2;\">\r\n <label for=\"fullName\">Full Name<\/label>\r\n <div class=\"field\"><input id=\"fullName\" name=\"fullName\" type=\"text\" required placeholder=\"First and last name\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"dob\">Date of Birth<\/label>\r\n <div class=\"field\"><input id=\"dob\" name=\"dob\" type=\"date\" required \/><\/div>\r\n <\/div>\r\n <div style=\"grid-column:1\/-1\">\r\n <label for=\"address\">Address<\/label>\r\n <div class=\"field\"><input id=\"address\" name=\"address\" type=\"text\" required placeholder=\"Street address\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"city\">City<\/label>\r\n <div class=\"field\"><input id=\"city\" name=\"city\" type=\"text\" required \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"state\">State<\/label>\r\n <div class=\"field\"><input id=\"state\" name=\"state\" type=\"text\" required maxlength=\"2\" placeholder=\"NY\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"zip\">ZIP<\/label>\r\n <div class=\"field\"><input id=\"zip\" name=\"zip\" type=\"text\" required pattern=\"\\\\d{5}(-\\\\d{4})?\" placeholder=\"10005\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"phone\">Phone<\/label>\r\n <div class=\"field\"><input id=\"phone\" name=\"phone\" type=\"tel\" required placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div>\r\n <div class=\"options\" style=\"margin-top:6px;\">\r\n <span style=\"font-weight:600;color:#1e315c;\">Preferred Contact<\/span>\r\n <label class=\"opt\"><input type=\"radio\" name=\"prefContact\" value=\"Phone\" required \/> Phone<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"prefContact\" value=\"SMS\" \/> SMS<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"prefContact\" value=\"Email\" \/> Email<\/label>\r\n <\/div>\r\n <\/div>\r\n <div style=\"grid-column: span 2;\">\r\n <label for=\"email\">Email Address<\/label>\r\n <div class=\"field\"><input id=\"email\" name=\"email\" type=\"email\" required placeholder=\"you@example.com\" \/><\/div>\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n \r\n <div class=\"section\">\r\n <h3>2. Prescription Information<\/h3>\r\n <div class=\"grid cols-3\">\r\n <div style=\"grid-column:1\/-1\">\r\n <label for=\"medName\">Medication Name<\/label>\r\n <div class=\"field\"><input id=\"medName\" name=\"medName\" type=\"text\" required \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"strength\">Strength (e.g., 500 mg)<\/label>\r\n <div class=\"field\"><input id=\"strength\" name=\"strength\" type=\"text\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"formMed\">Form (e.g., tablet, gel, rinse)<\/label>\r\n <div class=\"field\"><input id=\"formMed\" name=\"formMed\" type=\"text\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"dosage\">Current Dosage & Frequency<\/label>\r\n <div class=\"field\"><input id=\"dosage\" name=\"dosage\" type=\"text\" required placeholder=\"e.g., 1 tab twice daily\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"origDate\">Original Prescription Date<\/label>\r\n <div class=\"field\"><input id=\"origDate\" name=\"origDate\" type=\"date\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"rxNumber\">Prescription Number (if known)<\/label>\r\n <div class=\"field\"><input id=\"rxNumber\" name=\"rxNumber\" type=\"text\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"pharmacy\">Pharmacy Name<\/label>\r\n <div class=\"field\"><input id=\"pharmacy\" name=\"pharmacy\" type=\"text\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"pharmacyPhone\">Pharmacy Phone<\/label>\r\n <div class=\"field\"><input id=\"pharmacyPhone\" name=\"pharmacyPhone\" type=\"tel\" placeholder=\"(555) 123-4567\" pattern=\"^[0-9\\\\-\\\\+\\$\\$ ]{7,}$\" \/><\/div>\r\n <\/div>\r\n <\/div>\r\n <div style=\"margin-top:10px;\">\r\n <label for=\"refillReason\">Reason for Refill Request<\/label>\r\n <div class=\"field\"><textarea id=\"refillReason\" name=\"refillReason\"><\/textarea><\/div>\r\n <\/div>\r\n <\/div>\r\n \r\n <div class=\"section\">\r\n <h3>3. Symptom & Oral Health Screening<\/h3>\r\n <p>Are you currently experiencing any of the following? (Check all that apply)<\/p>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"sym\" value=\"New or worsening pain\" \/> New or worsening pain at treatment site<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"sym\" value=\"Swelling\" \/> Swelling of gums, face, or jaw<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"sym\" value=\"Bleeding\" \/> Bleeding from gums or oral tissues<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"sym\" value=\"Ulcers\/sores\/lesions\" \/> Ulcers, sores, or lesions in mouth<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"sym\" value=\"Sensitivity\" \/> Increased sensitivity to hot\/cold\/sweet<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"sym\" value=\"Dry mouth\" \/> Dry mouth or excessive salivation<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"sym\" value=\"Dysphagia\" \/> Difficulty swallowing or speaking<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"sym\" value=\"Other\" \/> Other<\/label>\r\n <\/div>\r\n <div class=\"field\" style=\"margin-top:8px;\"><input id=\"symOther\" name=\"symOther\" type=\"text\" placeholder=\"If Other, specify\" \/><\/div>\r\n <div style=\"margin-top:10px;\">\r\n <label>Symptom severity (0 = none; 10 = worst)<\/label>\r\n <div class=\"range-wrap\">\r\n <span>0<\/span>\r\n <input id=\"severity\" type=\"range\" min=\"0\" max=\"10\" step=\"1\" value=\"0\" oninput=\"document.getElementById('severityOut').value=this.value\" \/>\r\n <span>10<\/span>\r\n <output id=\"severityOut\">0<\/output>\r\n <\/div>\r\n <\/div>\r\n <div class=\"grid cols-2\" style=\"margin-top:10px;\">\r\n <div>\r\n <label>New medications\/supplements since last visit?<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"newMeds\" value=\"Yes\" \/> Yes<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"newMeds\" value=\"No\" \/> No<\/label>\r\n <\/div>\r\n <div class=\"field\" style=\"margin-top:8px;\"><input id=\"newMedsList\" name=\"newMedsList\" type=\"text\" placeholder=\"If Yes, list names and dosages\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label>Known allergies or adverse reactions?<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"allergy\" value=\"Yes\" \/> Yes<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"allergy\" value=\"No\" \/> No<\/label>\r\n <\/div>\r\n <div class=\"field\" style=\"margin-top:8px;\"><input id=\"allergyDesc\" name=\"allergyDesc\" type=\"text\" placeholder=\"If Yes, specify\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label>New medical condition since last visit?<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"newCondition\" value=\"Yes\" \/> Yes<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"newCondition\" value=\"No\" \/> No<\/label>\r\n <\/div>\r\n <div class=\"field\" style=\"margin-top:8px;\"><input id=\"newConditionDesc\" name=\"newConditionDesc\" type=\"text\" placeholder=\"If Yes, describe\" \/><\/div>\r\n <\/div>\r\n <div>\r\n <label>Currently pregnant or breastfeeding?<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"pregBF\" value=\"Yes\" \/> Yes<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"pregBF\" value=\"No\" \/> No<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"pregBF\" value=\"N\/A\" \/> N\/A<\/label>\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n \r\n <div class=\"section\">\r\n <h3>4. Medication Use & Compliance<\/h3>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"adherence\" value=\"Yes\" \/> I have been taking medication as directed<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"adherence\" value=\"No\" \/> No<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"adherence\" value=\"Sometimes\" \/> Sometimes<\/label>\r\n <\/div>\r\n <div class=\"field\" style=\"margin-top:8px;\"><input id=\"adherenceExplain\" name=\"adherenceExplain\" type=\"text\" placeholder=\"If No\/Sometimes, please explain\" \/><\/div>\r\n <p style=\"margin-top:10px;\">Side effects experienced (check all that apply)<\/p>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"side\" value=\"Nausea\" \/> Nausea or vomiting<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"side\" value=\"Dizziness\" \/> Dizziness or lightheadedness<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"side\" value=\"Rash\" \/> Rash or itching<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"side\" value=\"GI upset\" \/> Gastrointestinal upset<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"side\" value=\"Headache\" \/> Headache<\/label>\r\n <label class=\"opt\"><input type=\"checkbox\" name=\"side\" value=\"Other\" \/> Other<\/label>\r\n <\/div>\r\n <div class=\"field\" style=\"margin-top:8px;\"><textarea id=\"sideDetails\" name=\"sideDetails\" placeholder=\"If checked, describe severity and duration\"><\/textarea><\/div>\r\n <div style=\"margin-top:10px;\">\r\n <label>Do you have enough medication to last until the refill is processed?<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"enoughMed\" value=\"Yes\" \/> Yes<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"enoughMed\" value=\"No\" \/> No<\/label>\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n \r\n <div class=\"section\">\r\n <h3>5. Follow\u2011Up & Care Plan<\/h3>\r\n <div class=\"grid cols-2\">\r\n <div>\r\n <label>Do you require a telehealth consultation before approval?<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"needConsult\" value=\"Yes\" \/> Yes<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"needConsult\" value=\"No\" \/> No<\/label>\r\n <\/div>\r\n <\/div>\r\n <div>\r\n <label>Schedule a follow\u2011up teledentistry appointment?<\/label>\r\n <div class=\"options\">\r\n <label class=\"opt\"><input type=\"radio\" name=\"followUp\" value=\"Yes\" \/> Yes<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"followUp\" value=\"No\" \/> No<\/label>\r\n <\/div>\r\n <div class=\"options\" style=\"margin-top:8px;\">\r\n <span style=\"font-weight:600;color:#1e315c;\">Preferred time<\/span>\r\n <label class=\"opt\"><input type=\"radio\" name=\"prefTime\" value=\"Morning\" \/> Morning<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"prefTime\" value=\"Afternoon\" \/> Afternoon<\/label>\r\n <label class=\"opt\"><input type=\"radio\" name=\"prefTime\" value=\"Evening\" \/> Evening<\/label>\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n <div style=\"margin-top:10px;\">\r\n <label for=\"questions\">Questions or concerns about medication or treatment plan<\/label>\r\n <div class=\"field\"><textarea id=\"questions\" name=\"questions\"><\/textarea><\/div>\r\n <\/div>\r\n <\/div>\r\n \r\n <div class=\"section\">\r\n <h3>6. Authorization & Signature<\/h3>\r\n <ul class=\"note\" style=\"padding-left:18px; margin:8px 0;\">\r\n <li>The practice will review my request and may contact me for further assessment.<\/li>\r\n <li>Approval of a refill request is at the discretion of the prescribing provider.<\/li>\r\n <li>If clinical evaluation is required, I may be asked to schedule a virtual or in\u2011office visit.<\/li>\r\n <\/ul>\r\n <div class=\"options\" style=\"margin:10px 0;\">\r\n <label class=\"opt\"><input type=\"checkbox\" id=\"consentAck\" required \/> I certify the information is accurate and complete.<\/label>\r\n <\/div>\r\n <div class=\"grid cols-2\">\r\n <div>\r\n <label>Patient Signature<\/label>\r\n <div class=\"sig-pad\">\r\n <canvas class=\"signature\" id=\"sigPatient\" aria-label=\"Patient signature\"><\/canvas>\r\n <div class=\"sig-tools\"><button type=\"button\" class=\"btn\" data-clear=\"sigPatient\">Clear<\/button><\/div>\r\n <\/div>\r\n <\/div>\r\n <div>\r\n <label for=\"sigDate\">Date<\/label>\r\n <div class=\"field\"><input id=\"sigDate\" name=\"sigDate\" type=\"date\" required \/><\/div>\r\n <\/div>\r\n <\/div>\r\n <h3 style=\"margin-top:14px;\">If signed by guardian\/representative<\/h3>\r\n <div class=\"grid cols-2\">\r\n <div><label for=\"repName\">Name<\/label><div class=\"field\"><input id=\"repName\" name=\"repName\" type=\"text\" \/><\/div><\/div>\r\n <div><label for=\"repRel\">Relationship to Patient<\/label><div class=\"field\"><input id=\"repRel\" name=\"repRel\" type=\"text\" \/><\/div><\/div>\r\n <div>\r\n <label>Representative Signature<\/label>\r\n <div class=\"sig-pad\">\r\n <canvas class=\"signature\" id=\"sigRep\" aria-label=\"Representative signature\"><\/canvas>\r\n <div class=\"sig-tools\"><button type=\"button\" class=\"btn\" data-clear=\"sigRep\">Clear<\/button><\/div>\r\n <\/div>\r\n <\/div>\r\n <div><label for=\"repDate\">Date<\/label><div class=\"field\"><input id=\"repDate\" name=\"repDate\" type=\"date\" \/><\/div><\/div>\r\n <\/div>\r\n <\/div>\r\n <div class=\"section\">\r\n <p class=\"note\"><strong>Thank you for your request.<\/strong> We aim to process refill requests within 2 business days.<\/p>\r\n <\/div>\r\n <\/form>\r\n <div class=\"footer\">\r\n <div class=\"note\">Workflow: Print\/Preview your completed form \u2192 Save a PDF copy \u2192 Submit & upload to our secure Dropbox.<\/div>\r\n <div style=\"display:flex; gap:10px;\">\r\n <button type=\"button\" class=\"btn\" id=\"btnPrint2\">Print \/ Preview<\/button>\r\n <button type=\"button\" class=\"btn primary\" id=\"btnSave2\" disabled>Save PDF<\/button>\r\n <button type=\"button\" class=\"btn ok\" id=\"btnSubmit2\" disabled>Submit & Upload<\/button>\r\n <\/div>\r\n <\/div>\r\n<\/section>\r\n<\/main> <div class=\"toast\" id=\"toast\" role=\"status\" aria-live=\"polite\" aria-atomic=\"true\">Ready<\/div> <script src=\"https:\/\/cdn.jsdelivr.net\/npm\/html2pdf.js@0.10.1\/dist\/html2pdf.bundle.min.js\" crossorigin=\"anonymous\"><\/script> <script> (function(){ const dropboxURL = 'https:\/\/www.dropbox.com\/request\/gdRmWuwrMys3cW8R8Xua'; const form = document.getElementById('refill-form'); const card = document.getElementById('form-card'); const toast = document.getElementById('toast');\r\n const btnPrint = document.getElementById('btnPrint');\r\n const btnPrint2 = document.getElementById('btnPrint2');\r\n const btnSave = document.getElementById('btnSave');\r\n const btnSave2 = document.getElementById('btnSave2');\r\n const btnSubmit = document.getElementById('btnSubmit');\r\n const btnSubmit2 = document.getElementById('btnSubmit2');\r\n const btnClear = document.getElementById('btnClear');\r\n const st1 = document.getElementById('st1');\r\n const st2 = document.getElementById('st2');\r\n const st3 = document.getElementById('st3');\r\n \/\/ Signature pads\r\n const pads = {\r\n sigPatient: setupSignaturePad(document.getElementById('sigPatient')),\r\n sigRep: setupSignaturePad(document.getElementById('sigRep'))\r\n };\r\n document.querySelectorAll('[data-clear]').forEach(btn=>{\r\n btn.addEventListener('click', ()=>{\r\n const id = btn.getAttribute('data-clear');\r\n pads[id]?.clear();\r\n });\r\n });\r\n \/\/ Defaults\r\n const todayISO = (new Date()).toISOString().slice(0,10);\r\n const defaultDateIds = ['sigDate'];\r\n defaultDateIds.forEach(id => { const el = document.getElementById(id); if(el && !el.value) el.value = todayISO; });\r\n \/\/ State\r\n let hasPrinted = false;\r\n let hasSaved = false;\r\n function setSaveEnabled(on){ btnSave.disabled = !on; btnSave2.disabled = !on; }\r\n function setSubmitEnabled(on){ btnSubmit.disabled = !on; btnSubmit2.disabled = !on; }\r\n function updateSteps(){\r\n st1.classList.toggle('done', hasPrinted);\r\n st2.classList.toggle('done', hasSaved);\r\n st3.classList.toggle('done', hasSaved);\r\n setSaveEnabled(hasPrinted); \/\/ Save allowed only after print\/preview\r\n setSubmitEnabled(hasSaved); \/\/ Submit allowed only after save\r\n }\r\n updateSteps();\r\n \/\/ Toast helper\r\n let tmr;\r\n function showToast(msg){\r\n toast.textContent = msg;\r\n toast.classList.add('show');\r\n clearTimeout(tmr);\r\n tmr = setTimeout(()=> toast.classList.remove('show'), 1800);\r\n }\r\n \/\/ Validation\r\n function validateForm(){\r\n const reqIds = ['fullName','dob','address','city','state','zip','phone','email','medName','dosage','sigDate'];\r\n for(const id of reqIds){\r\n const el = document.getElementById(id);\r\n if(!el || (el.value || '').trim() === ''){\r\n el?.scrollIntoView({behavior:'smooth', block:'center'});\r\n el?.focus?.({preventScroll:true});\r\n showToast('Please complete required fields.');\r\n return false;\r\n }\r\n }\r\n if(!form.querySelector('input[name=\"prefContact\"]:checked')){\r\n showToast('Please select a preferred contact method.');\r\n form.querySelector('input[name=\"prefContact\"]')?.scrollIntoView({behavior:'smooth', block:'center'});\r\n return false;\r\n }\r\n const consent = document.getElementById('consentAck');\r\n if(!consent.checked){\r\n consent.scrollIntoView({behavior:'smooth', block:'center'});\r\n showToast('Please confirm the authorization.');\r\n return false;\r\n }\r\n if(pads.sigPatient.isBlank()){\r\n document.getElementById('sigPatient').scrollIntoView({behavior:'smooth', block:'center'});\r\n showToast('Please add your signature.');\r\n return false;\r\n }\r\n return true;\r\n }\r\n \/\/ Print\/Preview\r\n function doPrint(){\r\n if(!validateForm()) return;\r\n window.print();\r\n }\r\n btnPrint.addEventListener('click', doPrint);\r\n btnPrint2.addEventListener('click', doPrint);\r\n \/\/ Detect when print preview closes\r\n function afterPrint(){\r\n hasPrinted = true;\r\n updateSteps();\r\n showToast('Print preview closed. You can now save a PDF.');\r\n }\r\n if('onafterprint' in window){\r\n window.addEventListener('afterprint', afterPrint);\r\n }else{\r\n btnPrint.addEventListener('click', ()=> setTimeout(afterPrint, 3000));\r\n btnPrint2.addEventListener('click', ()=> setTimeout(afterPrint, 3000));\r\n }\r\n \/\/ Filename for PDF\r\n function makeFileName(){\r\n const name = (document.getElementById('fullName').value || 'Patient').trim().replace(\/\\s+\/g,'_');\r\n const date = (document.getElementById('sigDate').value || todayISO);\r\n return `Rx_Refill_Request_${name}_${date}.pdf`;\r\n }\r\n \/\/ Save PDF (html2pdf)\r\n async function savePDF(){\r\n if(!hasPrinted){\r\n showToast('Please print\/preview first.');\r\n return;\r\n }\r\n if(!validateForm()) return;\r\n await ensureSignatures();\r\n const opt = {\r\n margin: 0.4,\r\n filename: makeFileName(),\r\n image: { type: 'jpeg', quality: 0.98 },\r\n html2canvas: { scale: 2, useCORS: true, backgroundColor: '#ffffff' },\r\n jsPDF: { unit: 'in', format: 'letter', orientation: 'portrait' },\r\n pagebreak: { mode: ['css','legacy'] }\r\n };\r\n await html2pdf().from(card).set(opt).save();\r\n hasSaved = true;\r\n updateSteps();\r\n showToast('PDF saved to your device.');\r\n }\r\n btnSave.addEventListener('click', savePDF);\r\n btnSave2.addEventListener('click', savePDF);\r\n \/\/ Submit & Upload to Dropbox (redirect)\r\n async function submitAndUpload(){\r\n if(!hasSaved){\r\n showToast('Please save a PDF first.');\r\n return;\r\n }\r\n if(!validateForm()) return;\r\n try{\r\n const win = window.open(dropboxURL, '_blank');\r\n win?.focus();\r\n }catch(e){\r\n window.location.href = dropboxURL;\r\n }\r\n }\r\n btnSubmit.addEventListener('click', submitAndUpload);\r\n btnSubmit2.addEventListener('click', submitAndUpload);\r\n \/\/ Clear\r\n btnClear.addEventListener('click', ()=>{\r\n if(!confirm('Clear all fields and signatures?')) return;\r\n form.reset();\r\n defaultDateIds.forEach(id => { const el = document.getElementById(id); if(el) el.value = todayISO; });\r\n pads.sigPatient.clear();\r\n pads.sigRep.clear();\r\n hasPrinted = false; hasSaved = false;\r\n updateSteps();\r\n showToast('Form cleared.');\r\n });\r\n \/\/ Ensure signatures ready (canvas already holds strokes)\r\n async function ensureSignatures(){ return true; }\r\n \/\/ Signature pad\r\n function setupSignaturePad(canvas){\r\n const ctx = canvas.getContext('2d');\r\n const state = { drawing:false, blank:true, lastX:0, lastY:0 };\r\n function resize(){\r\n const ratio = Math.max(window.devicePixelRatio || 1, 1);\r\n const rect = canvas.getBoundingClientRect();\r\n canvas.width = rect.width * ratio;\r\n canvas.height = rect.height * ratio;\r\n ctx.setTransform(ratio, 0, 0, ratio, 0, 0);\r\n ctx.lineCap = 'round';\r\n ctx.lineJoin = 'round';\r\n ctx.lineWidth = 2.2;\r\n ctx.strokeStyle = '#18223b';\r\n ctx.clearRect(0,0,canvas.width,canvas.height);\r\n state.blank = true;\r\n }\r\n window.addEventListener('resize', resize, { passive:true });\r\n resize();\r\n function getPos(e){\r\n const r = canvas.getBoundingClientRect();\r\n const p = e.touches ? e.touches[0] : e;\r\n return { x: p.clientX - r.left, y: p.clientY - r.top };\r\n }\r\n function start(e){ e.preventDefault(); state.drawing=true; const p=getPos(e); state.lastX=p.x; state.lastY=p.y; }\r\n function move(e){\r\n if(!state.drawing) return;\r\n e.preventDefault();\r\n const p = getPos(e);\r\n ctx.beginPath(); ctx.moveTo(state.lastX, state.lastY); ctx.lineTo(p.x,p.y); ctx.stroke();\r\n state.lastX = p.x; state.lastY = p.y; state.blank = false;\r\n }\r\n function end(){ state.drawing=false; }\r\n canvas.addEventListener('mousedown', start);\r\n canvas.addEventListener('mousemove', move);\r\n window.addEventListener('mouseup', end);\r\n canvas.addEventListener('touchstart', start, { passive:false });\r\n canvas.addEventListener('touchmove', move, { passive:false });\r\n canvas.addEventListener('touchend', end);\r\n function clear(){ ctx.clearRect(0,0,canvas.width,canvas.height); state.blank = true; }\r\n function isBlank(){ return state.blank; }\r\n return { clear, isBlank };\r\n }\r\n})();\r\n<\/script> <\/body> <\/html>\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Your Smile Partners PLLC \u2014 Teledentistry Prescription Refill Request Form Teledentistry Prescription Refill Request Form Your Smile Partners PLLC 99 Wall St, New York, NY 10005 Email: talk@yoursmilepartners.com Phone: (212) 555\u2011SMILE Step 1: Print\/Preview Step 2: Save PDF Step 3: Submit & Upload Print \/ Preview Save PDF to Device Submit & Upload to Dropbox…<\/p>\n<p><a class=\"btn btn-outline-dark btn-sm anzu-read-more-link\" href=\"https:\/\/stephanie.openteledentistry.com\/?page_id=836\">Continue Reading<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"content-type":"","footnotes":""},"class_list":["post-836","page","type-page","status-publish","hentry"],"_hostinger_reach_plugin_has_subscription_block":false,"_hostinger_reach_plugin_is_elementor":false,"_links":{"self":[{"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=\/wp\/v2\/pages\/836","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=836"}],"version-history":[{"count":4,"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=\/wp\/v2\/pages\/836\/revisions"}],"predecessor-version":[{"id":840,"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=\/wp\/v2\/pages\/836\/revisions\/840"}],"wp:attachment":[{"href":"https:\/\/stephanie.openteledentistry.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=836"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}