<!-- BEGIN worklist/local/outreach/request_form.tt -->
<div class="request_form">
<div class="logo">
<img src='/images/logo.jpeg' alt="" />
</div>
<h1>[% c.cfg('settings').application_name %]</h1>
<p class="address">
[% c.cfg('settings').service_address %]<br />
Telephone: [% c.cfg('settings').service_telno %] ~ FAX: 0113 206 7883
~ E-mail: andy.rawstron@hmds.org.uk
</p>
<h2>Outreach Programme Request Form</h2>
<div class="details">
<p class="contact">In case of problems please contact Andy Rawstron on 07747 847 505</p>
<p class="header">Please complete fields highlighted in red, and correct any errors</p>
<table class="pid">
<tr>
<td class="label">Name:</td>
<td>[% entry.first_name | ucfirst %] [% entry.last_name | upper %]</td>
[% class = entry.dob ? 'normal' : 'highlight' %]
<td class="label">DoB:</td>
<td class="[% class %]">
[% entry.dob.strftime('%d.%b.%Y') %]
</td>
</tr>
<tr>
<td class="label">NHS No:</td>
<td>[% entry.nhs_number %]</td>
[% class = entry.unit_number ? 'normal' : 'highlight' %]
<td class="label">Patient ID:</td>
<td class="[% class %]">[% entry.unit_number %]</td>
</tr>
<tr>
<td class="label">GP:</td>
<td>[% entry.practitioner %]</td>
[% class = entry.gender ? 'normal' : 'highlight' %]
<td class="label">Gender:</td>
<td class="[% class %]">[% entry.gender %]</td>
</tr>
<tr>
<td class="label" valign="top">Practice:</td>
<td>[% entry.practice_address %]</td>
<td class="label">Phlebotomist:</td>
<td class="highlight"> </td>
</tr>
<tr>
<td class="label">Date:</td><td class="highlight"> </td>
<td class="label">Time:</td><td class="highlight"> </td>
</tr>
</table>
</div>
<div class="details">
<p class="header">Please enclose the following samples</p>
<div style="float: right">
<p>
<b>Tubes should be hand-labelled after collection.<br />
DO NOT use addressograph labels.</b>
</p>
</div>
<ul>
[% IF entry.blood_tube.match('vacutainer') %]
<li>1 x gold top serum</li>
<li>1 x red/yellow top serum</li>
<li>1 x purple top EDTA</li>
[% ELSE %]
<li>2 x brown top serum</li>
<li>1 x red top EDTA</li>
[% END %]
</ul>
</div>
<div class="details">
<p class="header">Previous diagnosis</p>
<h4>[% entry.diagnosis %]</h4>
</div>
<div class="lab_use">
<p class="header">For laboratory use only</p>
</div>
</div>
<!-- END worklist/local/outreach/request_form.tt -->