The Webpage
<!DOCTYPE html>
<html xmlns="http://www.w3.org/1999/xhtml">
<head>
<title>My Custom Intake</title>
</head>
<body>
<h1>My Custom Intake</h1>
<form action="https://mychirotouch.com/PatientIntake/Interface/webform.aspx" method="post">
<!--The following elements are required. Make them hidden types-->
<!-- Put in your Chirotouch Customer ID -->
<input type="hidden" name="ctclientid" value="{Your Client ID Goes Here}" />
<!-- This is a key that will allow you access to post to our system. Contact your Chirotouch support representative to get a key-->
<input type="hidden" name="ctdatakey" value="{Contact your Chirotouch support representative to get a key}"/>
<!-- This tells our system the data is coming from a custom website. DO NOT MODIFY -->
<input type="hidden" name="ctdatasource" value="webintake" />
<!-- Required by the system to be considered a valid page. These will populate in the Chirotouch database -->
<label>FirstName:</label> <input type="text" name="Patient_FirstName" /><br />
<label>LastName:</label> <input type="text" name="Patient_LastName" /><br />
<label>Email:</label> <input type="text" name="Patient_Email" /><br />
<!-- End Required fields -->
<!-- When you import the data into your ChiroTouch system the following field values will be saved to the database. None of these fields are required. -->
<label>Address:</label> <input type="text" name="Patient_Address" /><br />
<label>BirthDate:</label> <input type="text" name="Patient_BirthDate" /><br />
<label>City:</label> <input type="text" name="Patient_City" /><br />
<label>CellPhone:</label> <input type="text" name="Patient_CellPhone" /><br />
<label>CondAuto:</label> <input type="text" name="Patient_CondAuto" /><br />
<label>CondEmployment:</label> <input type="text" name="Patient_CondEmployment" /><br />
<label>CondOther:</label> <input type="text" name="Patient_CondOther" /><br />
<label>EmployerAddress:</label> <input type="text" name="Patient_EmployerAddress" /><br />
<label>EmployerCity:</label> <input type="text" name="Patient_EmployerCity" /><br />
<label>EmployerName:</label> <input type="text" name="Patient_EmployerName" /><br />
<label>EmployerState:</label> <input type="text" name="Patient_EmployerState" /><br />
<label>EmployerZip:</label> <input type="text" name="Patient_EmployerZip" /><br />
<label>EmploymentStatus:</label> <input type="text" name="Patient_EmploymentStatus" /><br />
<label>HomePhone:</label> <input type="text" name="Patient_HomePhone" /><br />
<label>InjuryDate:</label> <input type="text" name="Patient_InjuryDate" /><br />
<label>MaritalStatus:</label> <input type="text" name="Patient_MaritalStatus" /><br />
<label>MiddleName:</label> <input type="text" name="Patient_MiddleName" /><br />
<label>Occupation:</label> <input type="text" name="Patient_Occupation" /><br />
<label>OrigInjuryDate:</label> <input type="text" name="Patient_OrigInjuryDate" /><br />
<label>ReferredBy:</label> <input type="text" name="Patient_ReferredBy" /><br />
<label>ReferredPatientName:</label> <input type="text" name="Patient_ReferredPatientName" /><br />
<label>ReferringPhys:</label> <input type="text" name="Patient_ReferringPhys" /><br />
<label>Sex:</label> <input type="text" name="Patient_Sex" /><br />
<label>SSN:</label> <input type="text" name="Patient_SSN" /><br />
<label>State:</label> <input type="text" name="Patient_State" /><br />
<label>UnableWorkFromDate:</label> <input type="text" name="Patient_UnableWorkFromDate" /><br />
<label>UnableWorkToDate:</label> <input type="text" name="Patient_UnableWorkToDate" /><br />
<label>WorkPhone:</label> <input type="text" name="Patient_WorkPhone" /><br />
<label>Zip:</label> <input type="text" name="Patient_Zip" /><br />
<!-- END SPECIAL FIELDS -->
<!-- You can add any additional fields you would like. Example -->
<label>Height:</label> <input type="text" name="Height" /><br />
<label>Eye color:</label> <input type="text" name="Eye_Color" /><br />
<!-- END ADDITIONAL FIELDS -->
<!-- When Making the PDF form to accompany this webpage you must name the textboxs the same as you named them on your webpage.
The ChiroTouch system takes the name from the webpage and looks for it in the PDF, if it is found it populates that textbox with the value.
If it is not found it moves onto the next value.
In the example above I would add a textbox with Eye_Color as the name to make it populate when the data is imported by Chirotouch -->
<br />
<input type="submit" value="Submit Form" />
</form>
</body>
</html>