<div class="container" id="pdf">
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<a name="top">
<img src="/images/logo.jpg" title="LCC Logo"
border="0" align="right" alt="LCC Logo"/>
</a>
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<div class="row">
<div class="col-md-offset-6">[% data.barcode %]</div>
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<h2 class="text-center">
Haematological Malignancy Diagnostic Service Request Form
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<strong>Level 3, Leeds Cancer Centre, Bexley Wing, Beckett Street,
Leeds, LS9 7TF<br />Tel: 0113 2067851 FAX: 0113 2067883</strong>
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<h4 class="text-danger bg-danger">
Please telephone department if urgent result is required
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<td><span class="fieldname">Surname:</span>
<span class="text-uppercase">[% data.last_name %]</span>
</td>
<td><span class="fieldname">Forename(s):</span>
<span class="text-capitalize">[% data.first_name %]</span>
</td>
</tr>
<tr>
<td><span class="fieldname">NHS number:</span>
<span class="text-uppercase">[% data.nhs_number %]</span>
</td>
<td><span class="fieldname">Patient/unit number:</span>
<span class="">[% data.patient_number %]</span>
</td>
</tr>
<tr>
<td><span class="fieldname">DoB:</span>
<span class="">[% data.dob %]</span>
</td>
<td><span class="fieldname">Gender:</span>
<span class="text-capitalize">[% data.gender %]</span>
</td>
</tr>
<tr>
<td><span class="fieldname">Location:</span>
<span class="text-capitalize">[% data.location %]</span>
</td>
<td><span class="fieldname">Consultant:</span>
<span class="text-capitalize">[% data.referrer %]</span>
</td>
</tr>
<tr>
<td>
<span class="fieldname">Danger of infection:</span>
[% class = data.doi.match('YES')
? 'btn btn-danger btn-xs' : 'normal' %]
<span class="[% class %]">[% data.doi %]</span>
</td>
<td>
<span class="fieldname">Evidence of TB:</span>
[% class = data.tb.match('YES')
? 'btn btn-danger btn-xs' : 'normal' %]
<span class="[% class %]">[% data.tb %]</span>
</td>
</tr>
<tr>
<td colspan="2">
<span class="fieldname">Specimen type(s):</span>
[% data.specimen %]
</td>
</tr>
<tr>
<td colspan="2">
<span class="fieldname">Previously investigated:</span>
[% data.previous %]
</td>
</tr>
</table>
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<div class="col-md-6">
<table class="table table-condensed">
<tr>
<td colspan="2">
<span class="fieldname">Sample ref:</span>
[% data.sample_ref %]
</td>
<td rowspan="3">
<table class="table-condensed borderless">
<tr>
<td><span class="fieldname">Hb:</span> [% data.hb %]</td>
<td><span class="fieldname">WBC:</span> [% data.wbc %]</td>
</tr>
<tr>
<td><span class="fieldname">Neut:</span> [% data.neut %]</td>
<td><span class="fieldname">Lymphs:</span> [% data.lymph %]</td>
</tr>
<tr>
<td><span class="fieldname">Plts:</span> [% data.plt %]</td>
<td><span class="fieldname">Other:</span> [% data.other %]</td>
</tr>
</table>
</td>
</tr>
<tr>
<td colspan="2">
<span class="fieldname">Suspected diagnosis:</span>
[% data.diagnosis %]
</td>
</tr>
<tr>
<td colspan="2">
<span class="fieldname">Who should this report be
returned to?</span>
[% data.report_to %]
</td>
</tr>
<tr>
<td colspan="3">
<span class="fieldname">Recent chemo/radiotherapy
details:</span> [% data.treatment %]
</td>
</tr>
<tr>
<td colspan="3">
<span class="fieldname">Clinical details:</span>
[% data.clinical_details %]
</td>
</tr>
<tr>
<td>
<span class="fieldname">Specimen taken by:</span>
[% data.taken_by %]
</td>
<td>
<span class="fieldname">Contact details:</span>
[% data.contact %]
</td>
<td>
<span class="fieldname">Date/time:</span>
[% data.datetime %]
</td>
</tr>
</table>
</div>
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