<!-- BEGIN [% component.name %] -->
[% # INCLUDE dumper.tt dump = data.as_tree %]
<script type="text/javascript">
jQuery( function() {
$("#is_valid_date_min").Watermark("min");
$("#is_valid_date_hour").Watermark("hr");
$("#is_valid_date_day").Watermark("dd");
$("#is_valid_date_month").Watermark("mm");
$("#is_valid_date_year").Watermark("yyyy");
} );
</script>
[% BLOCK validate_date; IF c.cfg('use_cgi_ajax') %]
onChange="do_ajax(
['is_valid_date_day','is_valid_date_month','is_valid_date_year',
'is_valid_date_hour','is_valid_date_min' ],
['bad_datetime']
); return true;"
[% END; END %]
<table class="indent">
<tr>
<td class="label">Referrer:</td>
<td class="search_bar">
<input style="width: 150px" type="text" name="_referrer"
id="referrer_name" value="[% data.referrer_department.referrer.name %]" />
<input type="hidden" name="referrer_code" id="referrer_id" />
[% IF error_referrer_code %]
[% error_referrer_code %]
[% ELSE %]
[ <a href="[% app_url %]/config/clinicians">new</a> ]
[% END %]
</td>
</tr>
<tr>
<td class="label">Specimen:</td>
<td class="content">
<input class="field" type="text" name="specimen_code" id="is_valid_specimen"
value="[% request_data.specimen_map.item(data.id).sample_code.join(', ') %]"
[% IF c.cfg('use_cgi_ajax') %]
onChange="do_ajax(['is_valid_specimen'], ['bad_specimen']); return true;"
[% END %] [% site.html.on_focus %] />[% error_specimen_code %]
<span class="ajax_error"><em id="bad_specimen"></em></span>
</td>
</tr>
<tr>
<td class="label">Taken:</td>
<td class="content">
[% specimen_date = request_data.has_optional.request_specimen_detail
? data.request_specimen_detail.specimen_date : undef;
# INCLUDE dumper.tt dump = specimen_date %]
<input type="text" name="day" size="2" id="is_valid_date_day"
value="[% specimen_date.strftime('%d') %]"
[% PROCESS validate_date %] maxlength="2" class="[% class %]"
[% site.html.on_focus %] />
<input type="text" name="month" size="2" id="is_valid_date_month"
value="[% specimen_date.strftime('%m') %]"
[% PROCESS validate_date %] maxlength="2" class="[% class %]"
[% site.html.on_focus %] />
<input type="text" name="year" size="4" id="is_valid_date_year"
value="[% specimen_date.strftime('%Y') %]"
[% PROCESS validate_date %] maxlength="4" class="[% class %]"
[% site.html.on_focus %] />
<b>@</b>
<input type="text" name="hour" size="2" id="is_valid_date_hour"
value="[% specimen_date.strftime('%H') %]"
[% PROCESS validate_date %] maxlength="2" class="[% class %]"
[% site.html.on_focus %] />
<input type="text" name="minute" size="2" id="is_valid_date_min"
value="[% specimen_date.strftime('%M') %]"
[% PROCESS validate_date %] maxlength="2" class="[% class %]"
[% site.html.on_focus %] />
[% UNLESS error_day || error_year # set if date invalid %]
<span class="ajax_error"><em id="bad_datetime"></em></span>
[% END %]
[% error_day || error_year # set if date invalid %]
</td>
</tr>
[%
IF request_data.has_optional.clinical_trial;
trial_id = data.request_trial.trial_id;
trial_number = get_trial_number(patient.id, data.request_trial.trial_id);
END;
IF trials.size;
%]
<tr>
<td class="label">Trial/study:</td>
<td class="content">
<select name="trial_id" id="trial_id" [% site.html.on_focus %]>
<option value=""> </option>
[% FOREACH trial IN trials %]
<option value="[% trial.id %]"
[% 'selected' IF trial.id == trial_id %]>
[% trial.trial_name %]
</option>
[% END %]
</select>
[% error_trial_id %]
</td>
</tr>
<tr>
<td class="label">Trial no:</td>
<td class="content">
<input class="field" type="text" name="trial_number"
value="[% trial_number %]" />
[% error_trial_number %]
</td>
</tr>
[% END %]
[%
IF request_data.has_optional.external_ref;
external_ref = data.request_external_ref.external_reference;
END;
%]
<tr>
<td class="label">External ref:</td>
<td class="content">
<input class="field" type="text" name="external_reference"
value="[% external_ref %]" />
[% error_external_reference %]
</td>
</tr>
</table>
<!-- END [% component.name %] -->