The XML

<?xml version="1.0" encoding="utf-8" ?>

<!-- Upload your files to "https://mychirotouch.com/PatientIntake/Interface" To make them available in your chirotouch system -->

<LoginName>

<!-- REQUIRED FIELDS -->

  <Data>

    <!-- Put in your Chirotouch Customer ID -->

    <FieldName>ctclientid</FieldName>

    <FieldValue>{Your Client ID Goes Here}</FieldValue>

  </Data>

  <Data>

    <!-- This is a key that will allow you access to post to our system. Contact your Chirotouch support representative to get a key-->

    <FieldName>ctdatakey</FieldName>

    <FieldValue>{Contact your Chirotouch support representative to get a key}</FieldValue>

  </Data>

  <Data>

    <!-- This tells our system the data is coming from the web. DO NOT MODIFY -->

    <FieldName>ctdatasource</FieldName>

    <FieldValue>webintake</FieldValue>

  </Data>

  <!-- Required by the system to be considered a valid page. These will populate in the Chirotouch database -->

  <Data>

    <FieldName>Patient_FirstName</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

  <Data>

    <FieldName>Patient_LastName</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

  <Data>

    <FieldName>Patient_Email</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

<!-- 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. -->

  <Data>

    <FieldName></FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

  <Data>

    <FieldName>Patient_Address</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

  <Data>

    <FieldName>Patient_BirthDate</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

  <Data>

    <FieldName>Patient_City</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

  <Data>

    <FieldName>Patient_CellPhone</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

  <Data>

    <FieldName>Patient_CondAuto</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

  <Data>

    <FieldName>Patient_CondEmployment</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

  <Data>

    <FieldName>Patient_CondOther</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

  <Data>

    <FieldName>Patient_EmployerAddress</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

  <Data>

    <FieldName>Patient_EmployerCity</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

  <Data>

    <FieldName>Patient_EmployerName</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

  <Data>

    <FieldName>Patient_EmployerState</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

  <Data>

    <FieldName>Patient_EmployerZip</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

  <Data>

    <FieldName>Patient_EmploymentStatus</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

  <Data>

    <FieldName>Patient_HomePhone</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

  <Data>

    <FieldName>Patient_InjuryDate</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

  <Data>

    <FieldName>Patient_MaritalStatus</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

  <Data>

    <FieldName>Patient_MiddleName</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

  <Data>

    <FieldName>Patient_Occupation</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

  <Data>

    <FieldName>Patient_OrigInjuryDate</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

  <Data>

    <FieldName>Patient_ReferredBy</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

  <Data>

    <FieldName>Patient_ReferredPatientName</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

  <Data>

    <FieldName>Patient_ReferringPhys</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

  <Data>

    <FieldName>Patient_Sex</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

  <Data>

    <FieldName>Patient_SSN</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

  <Data>

    <FieldName>Patient_State</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

  <Data>

    <FieldName>Patient_UnableWorkFromDate</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

  <Data>

    <FieldName>Patient_UnableWorkToDate</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

  <Data>

    <FieldName>Patient_WorkPhone</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

  <Data>

    <FieldName>Patient_Zip</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

<!-- END SPECIAL FIELDS -->

 

 

<!-- You can add any additional fields you would like. Example -->

  <Data>

    <FieldName>Height</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

  <Data>

    <FieldName>Eye_Color</FieldName>

    <FieldValue>{Users Entered Value}</FieldValue>

  </Data>

<!-- END ADDITIONAL FIELDS -->

 

<!-- When Making the PDF form to accompany this XML you must name the textboxs the same as you named them in your XML.

The ChiroTouch system takes the name from the XML 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 -->

</LoginName>