[% META title = 'Request » New' -%]
[% # PROCESS dumper.tt dump = data %]
[% SET patient = data.case.patient %]
<h3>New request successful</h3>
<div class="indent">
<table>
<tr>
<td class="label">Last Name:</td>
<td class="data">
<input type="text" value="[% patient.last_name | upper %]"
[% site.html.readonly %] />
</td>
</tr>
<tr>
<td class="label">First Name(s):</td>
<td class="data">
[% SET fname = patient.first_name; SET mname = patient.middle_name %]
<input type="text" value="[% fname | ucfirst %] [% mname | ucfirst %]"
[% site.html.readonly %] />
</td>
</tr>
<tr>
<td class="label">D.o.B:</td>
<td class="data">
<input type="text" value="[% patient.dob.strftime('%d.%b.%Y') %]"
[% site.html.readonly %] />
</td>
</tr>
<tr>
<td class="label">NHS Number:</td>
<td class="data">
<input type="text" value="[% patient.nhs_number %]"
[% site.html.readonly %] />
</td>
</tr>
<tr>
<td class="label">Unit Number:</td>
<td class="data">
<input type="text" value="[% data.case.unit_number %]"
[% site.html.readonly %] />
</td>
</tr>
<tr>
<td class="label">Lab. Number:</td>
[% SET lab_number = c.cfg('settings').lab_number_prefix _ data.lab_number %]
<td class="data">
<input type="text" value="[% lab_number %]" [% site.html.readonly %] />
</td>
</tr>
<tr>
<td class="label">Specimen:</td>
<td class="data">
<input type="text" value="[% data.specimen | upper %]"
[% site.html.readonly %] />
</td>
</tr>
[% IF data.year %]
<tr>
<td class="label">Taken:</td>
<td class="data">
<input type="text" value="[% data.day _ '.' _ data.month _ '.'
_ data.year _ ' @ ' _ ( data.hour || '00' ) _ ':'
_ ( data.minute || '00' ) %]" [% site.html.readonly %] />
</td>
</tr>
[% END %]
<tr>
<td class="label">Source:</td>
<td class="data">
<input type="text" value="[% data.referral_source %]"
[% site.html.readonly %] />
</td>
</tr>
<tr>
<td class="label">Referrer:</td>
<td class="data">
<input type="text" value="[% data.referrer_name %]"
[% site.html.readonly %] />
</td>
</tr>
[% IF data.trial_name %]
<tr>
<td class="label">Trial name:</td>
<td class="data">
<input type="text" value="[% data.trial_name %]"
[% site.html.readonly %] />
</td>
</tr>
<tr>
<td class="label">Trial number:</td>
<td class="data">
<input type="text" value="[% data.trial_number %]"
[% site.html.readonly %] />
</td>
</tr>
[% END %]
[% IF data.external_reference %]
<tr>
<td class="label">External ref:</td>
<td class="data">
<input type="text" value="[% data.external_reference %]"
[% site.html.readonly %] />
</td>
</tr>
[% END %]
<tr>
<td colspan="2" align="right">
<a href="[% app_url %]/register">Next »</a>
</td>
</tr>
</table>
</div>