<!-- BEGIN [% component.name %] -->
[% PROCESS site/autosuggest.tt %]
<script type="text/javascript">
jQuery( function() {
$("#is_valid_date_dob_day").Watermark("dd");
$("#is_valid_date_dob_month").Watermark("mm");
$("#is_valid_date_dob_year").Watermark("yyyy");
$("#is_valid_date_req_day").Watermark("dd");
$("#is_valid_date_req_month").Watermark("mm");
$("#is_valid_date_req_year").Watermark("yyyy");
} );
</script>
<div class="indent">
<table>
<tr>
<td class="label">Last Name:</td>
<td class="content">
<input class="field" type="text" name="last_name" size="40"
[% site.html.on_focus %] /> [% error_last_name %]
</td>
</tr>
<tr>
<td class="label">First Name:</td>
<td class="content">
<input class="field" type="text" name="first_name" size="40"
[% site.html.on_focus %] /> [% error_first_name %]
</td>
</tr>
<tr>
<td class="label">NHS Number:</td>
<td class="content">
<input class="field" type="text" name="nhs_number" size="12"
id="is_valid_nhsno"
[% IF c.cfg('use_cgi_ajax') %]
onChange="do_ajax(['is_valid_nhsno'], ['bad_nhsno']); return true;"
[% END %] [% site.html.on_focus %] />
[% error_nhs_number %]
<span class="ajax_error"><em id="bad_nhsno"></em></span>
<span class="box">Patient No:</span>
<input class="field" type="text" name="unit_number" size="12"
[% site.html.on_focus %] /> [% error_unit_number %]
</td>
</tr>
[% BLOCK validate_dob; IF c.cfg('use_cgi_ajax') %]
onChange="do_ajax(
[
'is_valid_date_dob_day',
'is_valid_date_dob_month',
'is_valid_date_dob_year'
],
['bad_dob']
); return true;"
[% END; END %]
<tr>
[% SET class = error_dob_year || error_dob_day
? 'input_error' : 'field' %]
<td class="label">DoB:</td>
<td class="content">
<input type="text" name="dob_day" size="2" maxlength="2"
id="is_valid_date_dob_day" [% PROCESS validate_dob %]
class="[% class %]" [% site.html.on_focus %] />
<input type="text" name="dob_month" size="2" maxlength="2"
id="is_valid_date_dob_month" [% PROCESS validate_dob %]
class="[% class %]" [% site.html.on_focus %] />
<input type="text" name="dob_year" size="4" maxlength="4"
id="is_valid_date_dob_year" [% PROCESS validate_dob %]
class="[% class %]" [% site.html.on_focus %] />
[% UNLESS error_dob_day || error_dob_year # set if date invalid %]
<span class="ajax_error"><em id="bad_dob"></em></span>
[% END %]
[% error_dob_day || error_dob_year # set if date invalid %]
</td>
</tr>
<tr>
<td colspan="2" class="borderless"> </td>
</tr>
<tr>
<td class="label">Lab No:</td>
<td class="content">
<input class="field" type="text" name="lab_number" size="12"
[% site.html.on_focus %] />[% error_lab_number %]
<span class="box">Specimen:</span>
<input class="field" type="text" name="specimen_code" size="5"
id="is_valid_specimen"
[% 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>
[% BLOCK validate_date; IF c.cfg('use_cgi_ajax') %]
onChange="do_ajax(
[
'is_valid_date_req_day',
'is_valid_date_req_month',
'is_valid_date_req_year'
],
['bad_date']
); return true;"
[% END; END %]
<tr>
[% SET class = error_request_year || error_request_day
? 'input_error' : 'field' %]
<td class="label">Request date:</td>
<td class="content">
<input type="text" name="request_day" size="2" maxlength="2"
id="is_valid_date_req_day" [% PROCESS validate_date %]
class="[% class %]" [% site.html.on_focus %] />
<input type="text" name="request_month" size="2" maxlength="2"
id="is_valid_date_req_month" [% PROCESS validate_date %]
class="[% class %]" [% site.html.on_focus %] />
<input type="text" name="request_year" size="4" maxlength="4"
id="is_valid_date_req_year" [% PROCESS validate_date %]
class="[% class %]" [% site.html.on_focus %] />
[% UNLESS error_request_day || error_request_year # set if date invalid %]
<span class="ajax_error"><em id="bad_date"></em></span>
[% END %]
[% error_request_day || error_request_year # set if date invalid %]
<div style="display: inline; float: right; margin: 0 30px">
<input type="radio" name="date_extend" value="all_before" />
<span class="acronym" title="and all before">≤</span>
<b>OR</b>
<input type="radio" name="date_extend" value="all_after" />
<span class="acronym" title="and all after">≥</span>
</div>
</td>
</tr>
<tr>
<td class="label">Source:</td>
<td class="content">
<input style="width: 300px" type="text" id="location_name" />
<input type="hidden" id="source_id" name="referral_source_id" />
</td>
</tr>
<tr>
<td class="label">Referrer:</td>
<td class="content">
<input class="field" type="text" name="referrer_name" size="30"
[% site.html.on_focus %] />[% error_referrer_name %]
</td>
</tr>
<tr>
<td colspan="2" class="borderless"> </td>
</tr>
[% 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 %]">
[% trial.trial_name | html %]
</option>
[% END %]
</select>
<span class="box">Trial No:</span>
<input class="field" type="text" name="trial_number" size="12"
[% site.html.on_focus %] />[% error_trial_number %]
</td>
</tr>
[% END %]
<tr>
<td class="label">Urgent:</td>
<td class="content">
<input type="checkbox" name="urgent" value="1" />
<span class="box">Copy required:</span>
<input type="checkbox" name="copy_to" value="1" />
<span class="box">Private:</span>
<input type="checkbox" name="private" value="1" />
<span class="info" style="font-size: smaller">
« select 1 only
</span>
</td>
</tr>
<tr>
<td class="label">External Ref:</td>
<td class="content">
<input class="field" type="text" name="external_reference" size="30"
[% site.html.on_focus %] />[% error_block_ref %]
</td>
</tr>
</table>
</div>
<!-- END [% component.name %] -->