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  3. F568 - eSignature Modal

F568 - eSignature Modal

Description: This is the 508 compliant static HTML/CSS mock up of the eSignature view.

Documents: Please also view eSignature Modal wireframe, Workflow Diagram [PDF, 465KB], and Use Scenario Case Documentation [PDF, 140KB] for full details on implementation.

SINGLE Signing with Service Connection/Rate Disability and Related Information

Sign

Please indicate if the order is related to the following treatment factors.
All Orders Except Controlled Substance Orders.

New Toggle Options Checklist Control markup
Sodium Chloride Tab 1gm Take two tablets by mouth 5XD Quantity: 300 Refill: 0

Service Connected

Combat Veteran

Agent Orange Exposure

Ionizing Radiation Exposure

Southwest Asia Conditions

Shipboard Hazard and Defense

Military Sexual Trauma

Head and Neck Cancer

Old markup
Sodium Chloride Tab 1gm Take two tablets by mouth 5XD Quantity: 300 Refill: 0

Service Connected

Combat Veteran

Agent Orange Exposure

Ionizing Radiation Exposure

Southwest Asia Conditions

Shipboard Hazard and Defense

Military Sexual Trauma

Head and Neck Cancer

Service Connection & Rated Disabilities

Service Connected: 10%

Rated Disabilities: None Stated

Requried field alert.

Sign

Please indicate if the order is related to the following treatment factors.*
All Orders Except Controlled Substance Orders.

Sodium Chloride Tab 1gm Take two tablets by mouth 5XD Quantity: 300 Refill: 0

Service Connected

Combat Veteran

Agent Orange Exposure

Ionizing Radiation Exposure

Southwest Asia Conditions

Shipboard Hazard and Defense

Military Sexual Trauma

Head and Neck Cancer

Service Connection & Rated Disabilities

Service Connected: 10%

Rated Disabilities: None Stated

Sign

Please indicate if the order is related to the following treatment factors.*
All Orders Except Controlled Substance Orders.

Sodium Chloride Tab 1gm Take two tablets by mouth 5XD Quantity: 300 Refill: 0

Service Connected

Combat Veteran

Agent Orange Exposure

Ionizing Radiation Exposure

Southwest Asia Conditions

Shipboard Hazard and Defense

Military Sexual Trauma

Head and Neck Cancer

Service Connection & Rated Disabilities

Service Connected: 10%

Rated Disabilities: None Stated

MULTIPLE Signing with Service Connection/Rate Disability and Related Information

Sign

Please indicate if the order is related to the following treatment factors.
All Orders Except Controlled Substance Orders.

Sodium Chloride Tab 1gm Take two tablets by mouth 5XD Quantity: 300 Refill: 0

Service Connected

Combat Veteran

Agent Orange Exposure

Ionizing Radiation Exposure

Southwest Asia Conditions

Shipboard Hazard and Defense

Military Sexual Trauma

Head and Neck Cancer

Sodium Chloride Tab 1gm Take two tablets by mouth 5XD Quantity: 300 Refill: 0

Service Connected

Combat Veteran

Agent Orange Exposure

Ionizing Radiation Exposure

Southwest Asia Conditions

Shipboard Hazard and Defense

Military Sexual Trauma

Head and Neck Cancer

Sodium Chloride Tab 1gm Take two tablets by mouth 5XD Quantity: 300 Refill: 0

Service Connected

Combat Veteran

Agent Orange Exposure

Ionizing Radiation Exposure

Southwest Asia Conditions

Shipboard Hazard and Defense

Military Sexual Trauma

Head and Neck Cancer

Sodium Chloride Tab 1gm Take two tablets by mouth 5XD Quantity: 300 Refill: 0

Service Connected

Combat Veteran

Agent Orange Exposure

Ionizing Radiation Exposure

Southwest Asia Conditions

Shipboard Hazard and Defense

Military Sexual Trauma

Head and Neck Cancer

Sodium Chloride Tab 1gm Take two tablets by mouth 5XD Quantity: 300 Refill: 0

Service Connected

Combat Veteran

Agent Orange Exposure

Ionizing Radiation Exposure

Southwest Asia Conditions

Shipboard Hazard and Defense

Military Sexual Trauma

Head and Neck Cancer

Sodium Chloride Tab 1gm Take two tablets by mouth 5XD Quantity: 300 Refill: 0

Service Connected

Combat Veteran

Agent Orange Exposure

Ionizing Radiation Exposure

Southwest Asia Conditions

Shipboard Hazard and Defense

Military Sexual Trauma

Head and Neck Cancer

Sodium Chloride Tab 1gm Take two tablets by mouth 5XD Quantity: 300 Refill: 0

Service Connected

Combat Veteran

Agent Orange Exposure

Ionizing Radiation Exposure

Southwest Asia Conditions

Shipboard Hazard and Defense

Military Sexual Trauma

Head and Neck Cancer

Sodium Chloride Tab 1gm Take two tablets by mouth 5XD Quantity: 300 Refill: 0

Service Connected

Combat Veteran

Agent Orange Exposure

Ionizing Radiation Exposure

Southwest Asia Conditions

Shipboard Hazard and Defense

Military Sexual Trauma

Head and Neck Cancer

Total Selected: 5

Service Connection & Rated Disabilities

Service Connected: 10%

Rated Disabilities: None Stated

MULTIPLE Signing with Electronic Signature Code

Sign

Total Selected: 5

SINGLE Signing with Electronic Signature Code

Sign

MULTIPLE Signing with Various Types w/Categories

Sign

Outpatient Meds

Please indicate if the order is related to the following treatment factors.
All Orders Except Controlled Substance Orders.

Sodium Chloride Tab 1gm Take two tablets by mouth 5XD Quantity: 300 Refill: 0

Service Connected

Combat Veteran

Agent Orange Exposure

Ionizing Radiation Exposure

Southwest Asia Conditions

Shipboard Hazard and Defense

Military Sexual Trauma

Head and Neck Cancer


Labs

Total Selected: 2

Service Connection & Rated Disabilities

Service Connected: 10%

Rated Disabilities: None Stated