

INSERT INTO `forms` (`id`, `form_name`, `form_data`) VALUES (82, 'patient_agreement', '{\"formSections\":[{\"id\":\"user-form-settings\",\"componentType\":\"form\",\"component\":{\"ajax\":\"false\",\"attr\":\"novalidate\",\"framework\":\"bs4\",\"iconFont\":\"fontawesome5\",\"iconFontUrl\":\"//cdnjs.cloudflare.com/ajax/libs/font-awesome/5.3.1/css/all.min.css\",\"id\":\"patient_agreement\",\"layout\":\"horizontal\",\"plugins\":[],\"aftervalidation\":\"\",\"redirectUrl\":\"\",\"senderEmail\":\"\",\"recipientEmail\":\"\",\"subject\":\"\",\"senderName\":\"\",\"replyToEmail\":\"\",\"sentMessage\":\"\",\"dbTable\":\"\",\"dbPrimary\":\"\",\"dbFilter\":\"\"}},{\"id\":\"d3ds0akutwgqeb82td3zq\",\"componentType\":\"input\",\"component\":{\"componentType\":\"input\",\"helper\":\"\",\"icon\":\"\",\"iconPosition\":\"before\",\"plugins\":[],\"attr\":[],\"clazz\":\"\",\"index\":1,\"label\":\"Client Representatives\",\"name\":\"client_representatives\",\"placeholder\":\"\",\"type\":\"text\",\"value\":\"\",\"width\":\"100%\"}},{\"id\":\"2zghbmwra9wazlphzzqshj\",\"componentType\":\"input\",\"component\":{\"componentType\":\"input\",\"helper\":\"\",\"icon\":\"\",\"iconPosition\":\"before\",\"plugins\":[],\"attr\":[],\"clazz\":\"\",\"index\":2,\"label\":\"Relationship\",\"name\":\"relationship\",\"placeholder\":\"\",\"type\":\"text\",\"value\":\"\",\"width\":\"100%\"}},{\"id\":\"3o7oplhpu98g7m8pz68yf\",\"componentType\":\"input\",\"component\":{\"componentType\":\"input\",\"helper\":\"\",\"icon\":\"\",\"iconPosition\":\"before\",\"plugins\":[],\"attr\":[],\"clazz\":\"\",\"index\":3,\"label\":\"Witness\",\"name\":\"witness\",\"placeholder\":\"\",\"type\":\"text\",\"value\":\"\",\"width\":\"100%\"}},{\"id\":\"xd9ho8u8x9octivm9htui\",\"componentType\":\"checkbox\",\"component\":{\"componentType\":\"checkbox\",\"helper\":\"\",\"plugins\":[],\"checkboxes\":[{\"index\":1,\"text\":\"I authorize the staff to provide services, as requested by myself/representative and ordered by my physician. Services provided by Caregiver Pro Homecare, Inc. may include nursing, home health aide, personal care aide, social worker, dietician/nutritionist,  physical therapist, speech therapist, occupational therapist, audiologist, respiratory therapist, homemaker, and housekeeper\",\"value\":\"Yes\"}],\"attr\":[],\"clazz\":\"\",\"index\":1,\"inline\":\"true\",\"label\":\"\",\"name\":\"i_authorize_the_staff_to_provide_services\",\"value\":\"\",\"width\":\"100%\"}},{\"id\":\"h9olgr45fuukg7tntyvw\",\"componentType\":\"checkbox\",\"component\":{\"componentType\":\"checkbox\",\"helper\":\"\",\"plugins\":[],\"checkboxes\":[{\"index\":1,\"text\":\"The services provided  by Caregiver Pro Homecare, Inc. will have been explained to me and I  understand that I  may ref use treatment within the confines of the law after being  informed  of the consequences of  my action\",\"value\":\"Yes\"}],\"attr\":[],\"clazz\":\"\",\"index\":2,\"inline\":\"true\",\"label\":\"\",\"name\":\"the_services_provided_by_caregiver_pro_homecare\",\"value\":\"\",\"width\":\"100%\"}},{\"id\":\"7glyt39u2oatyvluy48zig\",\"componentType\":\"checkbox\",\"component\":{\"componentType\":\"checkbox\",\"helper\":\"\",\"plugins\":[],\"checkboxes\":[{\"index\":1,\"text\":\"I give my consent and authorization for release of medical information  to Caregiver Pro Homecare, Inc. by physician  and other health care provider facilities\",\"value\":\"Yes\"}],\"attr\":[],\"clazz\":\"\",\"index\":3,\"inline\":\"true\",\"label\":\"\",\"name\":\"i_give_my_consent_and_authorization_for_release\",\"value\":\"\",\"width\":\"100%\"}},{\"id\":\"s2z7ubxgndk3j26acimptt\",\"componentType\":\"checkbox\",\"component\":{\"componentType\":\"checkbox\",\"helper\":\"\",\"plugins\":[],\"checkboxes\":[{\"index\":1,\"text\":\"I authorize Caregiver Pro Homecare, Inc. and other licensing/regulatory bodies to periodically examine my medical record for the purpose of checking compliance to the applicable rules, regulations, and standards\",\"value\":\"Yes\"}],\"attr\":[],\"clazz\":\"\",\"index\":4,\"inline\":\"true\",\"label\":\"\",\"name\":\"i_authorize_caregiver_pro_home\",\"value\":\"\",\"width\":\"100%\"}},{\"id\":\"d797qjadilrhjaryutfrdu\",\"componentType\":\"checkbox\",\"component\":{\"componentType\":\"checkbox\",\"helper\":\"\",\"plugins\":[],\"checkboxes\":[{\"index\":1,\"text\":\"I  understand that it would be prudent and in my best interest to establish a Home Health Service Plan of Care in the event of an emergency such as a fire, hurricane, severe snowstorm, or other natural disaster. Therefore, I hereby grant Caregiver Pro Homecare, i nc. permission to reveal to any governmental agency, supplemental provider agency, community volunteer service, or any other providers of services, medical records regarding my nursing care, except where otherwise prohibited by law. I further understand this would be done as necessary, upon request, in order to ensure a safe and effective emergency preparedness plan of care\",\"value\":\"Yes\"}],\"attr\":[],\"clazz\":\"\",\"index\":5,\"inline\":\"true\",\"label\":\"\",\"name\":\"i_understand_that_it_would_be_prudent\",\"value\":\"\",\"width\":\"100%\"}},{\"id\":\"hegd9h0mbyfa6t8kc9y6e\",\"componentType\":\"checkbox\",\"component\":{\"componentType\":\"checkbox\",\"helper\":\"\",\"plugins\":[],\"checkboxes\":[{\"index\":1,\"text\":\"I acknowledge receiving verbal and written information concerning my Rights and Responsibilities as a home care client and the NYS Proxy Law/Advance Directives. I n addition the agency has provided a written procedure f or submitting complaints and concerns, and directions regarding contacting the agency after hours, on weekends, and holidays\",\"value\":\"Yes\"}],\"attr\":[],\"clazz\":\"\",\"index\":6,\"inline\":\"true\",\"label\":\"\",\"name\":\"i_acknowledge_receiving_verbal\",\"value\":\"\",\"width\":\"100%\"}},{\"id\":\"bj0b72rcackolnhsv318tc\",\"componentType\":\"checkbox\",\"component\":{\"componentType\":\"checkbox\",\"helper\":\"\",\"plugins\":[],\"checkboxes\":[{\"index\":1,\"text\":\"I agree that I (or my representative) shall be directly responsible for payment for all home care services provided according to this service agreement. I u understand that the invoices are rendered weekly and payable upon receipt. 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INSERT INTO `form_template_mapping` (`id`, `form_name`, `template_id`) VALUES (NULL, 'patient_agreement', '82');


ALTER TABLE `patient_report` ADD `patient_agreement` TEXT NOT NULL AFTER `report_entry_date`;


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ALTER TABLE `patient_report` CHANGE `body_mark_base64` `body_mark_base64` LONGTEXT CHARACTER SET utf8mb4 COLLATE utf8mb4_general_ci NULL DEFAULT NULL;


ALTER TABLE `patient_report` CHANGE `feet_mark_base64` `feet_mark_base64` LONGTEXT CHARACTER SET utf8mb4 COLLATE utf8mb4_general_ci NULL DEFAULT NULL;