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<!-- BEGIN [% template.name %] -->
  [% # INCLUDE dumper.tt dump = request %]
  [% # INCLUDE dumper.tt dump = params %]

  <div class="container">
    <div class="row">
        [% PROCESS banners.tt; logo = logo.large %]
        <img src="[% request.uri_base %]/images/[% logo %]" alt=""
           class="img-responsive" border="0" align="right" />
    </div>

    <div class="row">
        <fieldset><legend>HMDS BCR-ABL Monitoring Request Form</legend></fieldset>
    </div>
    
    <div class="row indent">
      <div class="btn-toolbar">
        <form method="post" action="[% request.uri_base %]/search"
            class="col-md-4 input-group">
          <div class="input-group-addon">NHS number:
            [% IF errs.nhs_number %]<span class="dfv-err">invalid</span>[% END %]
          </div>
          <input type="hidden" name="bcr_abl_req" value="1" />
          <input name="nhs_number" required="" id="nhs_number" type="text"
              class="input-medium form-control" value="[% params.nhs_number %]"
              maxlength="150" />
          <span class="input-group-btn">
            <button class="btn btn-primary" id="nhsno_result" type="submit">
              Search</button>
          </span>
        </form>
      </div>
    </div>
    </div>
  
    [% INCLUDE nhs_number_ajax.tt %]
<!-- END [% template.name %] -->