<!-- BEGIN [% component.name %] -->
[% # PROCESS dumper.tt dump = entry %]
[% BLOCK details %]
<table class="details">
<tr>
<td width="30%">Surname: [% entry.last_name | upper %]</td>
<td width="30%">
[% # generate array of forenames:
forenames = [];
first_name = entry.first_name | ucfirst;
middle_name = entry.middle_name | ucfirst;
forenames.push(first_name);
forenames.push(middle_name) IF middle_name;
%]
Forename(s): [% forenames.join(', ') %]
</td>
<td width="40%">Sample date:</td>
</tr>
<tr>
<td>
NHS number:
[% INCLUDE site/nhs_number.tt nhs_number = entry.nhs_number %]
</td>
<td>Patient number: [% entry.unit_number %]</td>
<td>Sample time:</td>
</tr>
<tr>
<td>Date of birth: [% entry.dob.strftime('%d.%b.%Y') %]</td>
<td>Male / Female: [% entry.gender %]</td>
<td>Phlebotomist name:</td>
</tr>
<tr>
<td>Ward/clinic: HMDS</td>
<td>Consultant: Rawstron</td>
<td> </td>
</tr>
</table>
[% END %]
<!-- biochemistry request form -->
<div class="path_request">
<table>
<tr>
<td>
<img src='/images/trustlogo_large.png' alt="" />
</td>
<td rowspan="2">
<div id="biochem">
<div>Biochemistry</div>
<div>SJUH site</div>
</diV>
</td>
</tr>
<tr>
<td>
<h3>BLOOD SCIENCES: BIOCHEMISTRY SJUH</h3>
</td>
</tr>
</table>
[% INCLUDE details %]
<div class="border">
<p class="">Diagnosis: [% entry.diagnosis %]</p>
<p class="strong">Chemistry Requests</p>
[% request_this = entry.pathology.biochem; # PROCESS dumper.tt dump = request_this %]
<ul>
[% IF request_this.albumin %]<li>Albumin</li>[% END %]
[% IF request_this.calcium %]<li>Calcium</li>[% END %]
[% IF request_this.creatinine %]<li>Creatinine</li>[% END %]
[% IF request_this.u_and_e %]<li>U&E</li>[% END %]
[% IF request_this.lft %]<li>LFT</li>[% END %]
[% IF request_this.mg %]<li>Magnesium</li>[% END %]
</ul>
<p class="strong">Please process aged samples</p>
</div>
</div>
<div style="padding: 30px"> </div>
<div class="path_request" style="page-break-after: always">
[% IF entry.pathology.immunology # not required for CML %]
<!-- immunology request form -->
<table>
<tr>
<td>
<img src='/images/trustlogo_large.png' alt="" />
</td>
<td rowspan="2">
<div id="immunol">
<div>Clinical Immunology</div>
<div>Old Medical School</div>
<div>LGI site</div>
</div>
</td>
</tr>
<tr>
<td>
<h3>IMMUNOLOGY LGI</h3>
</td>
</tr>
</table>
[% INCLUDE details %]
<div class="border">
<p class="">Diagnosis: [% entry.diagnosis %]</p>
<p class="strong">Immunology</p>
[% request_this = entry.pathology.immunology; # PROCESS dumper.tt dump = request_this %]
<ul>
[% IF request_this.igs %]<li>Immunoglobulins (GAM)</li>[% END %]
[% IF request_this.sep %]<li>Serum electrophoresis</li>[% END %]
[% IF request_this.ppq %]<li>Paraprotein/immunofixation if indicated</li>[% END %]
</ul>
</div>
[% END %]
</div>
<!-- END [% component.name %] -->