<!-- BEGIN worklist/local/outreach/request_form.tt -->
  <div class="request_form">
    <div align="center">
    	<img src='/images/outreach_header.png' alt="" />
    </div>

    <p class="address">
      [% c.cfg('settings').lab_name_abbreviation %],
      [% c.cfg('settings').service_address %]
    	Telephone: [% c.cfg('settings').service_telno %] ~ FAX: 0113 206 7883
    </p>

    <h2>Outreach Programme Request Form</h2>

    <div class="details">
    	<p class="contact">
        In case of problems please contact Andy Rawstron 
        [% c.cfg('settings').service_telno %] / 07747 847 505 / andy.rawstron@nhs.net       
      </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">Source:</td>
          <td>[% entry.location %]</td>
    			<td class="label">Clinician:</td>
          <td>[% entry.referrer %]</td>
    		</tr>

        <tr>
          <td colspan="4">GP: [% entry.practice_address %]</td>
        </tr>

        <tr>
          <td colspan="4">
            <p class="strong">Previous diagnosis: [% entry.diagnosis %]</p>
          </td>
        </tr>

    	</table>
    </div>

	  
    <div class="details">
      <div class="strong">FOR PATIENT TO COMPLETE:</div>

      <p class="indent">
        Are you happy with the way your disorder is being monitored?
      </p>
      
	        <table class="indent">
        <tr>
          <td align="right">YES:</td>
          <td>
            <input type="text" class="date" /> NO
            <input type="text" class="date" /> If no please provide details overleaf           
          </td>
        </tr>
        <tr>
	</table>
    </div>
    
    <div class="details">
      <div class="strong">FOR PHLEBOTOMIST TO COMPLETE (please also complete biochemistry and immunology request forms):</div>
      
      <table class="indent">
        <tr>
          <td align="right">Date / Time:</td>
          <td>
            <input type="text" class="date" /> /
            <input type="text" class="date" />            
          </td>
        </tr>
        <tr>
          <td>Phlebotomist:</td>
          <td><input type="text" class="name" /></td>
        </tr>
      </table>
      
     	<p class="header">Please enclose the following samples</p>

      <div style="float: right">
    		<p>
          <b>Tubes should be hand-labelled after collection.<br />
          Please DO NOT use addressograph labels.</b>
        </p>
    	</div>

    	<ul>
        [% tube_type_required = entry.tube_type # only supplied if practice override in place
			  || tube_type(entry.practice_post_code); # callback in Controller
            IF tube_type_required.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="lab_use">
     	<p class="header">For laboratory use only</p>
    </div>
  </div>
<!-- END worklist/local/outreach/request_form.tt -->