<!-- BEGIN [% template.name %] -->
[% # INCLUDE dumper.tt dump = request %]
[% # INCLUDE dumper.tt dump = params %]
[% PROCESS headers.tt; # sets header
# INCLUDE dumper.tt dump = header %]
<div class="container">
<div class="row">
<img src="[% request.uri_base %]/images/[% header.logos.large %]" alt=""
class="img-responsive" border="0" align="right" />
</div>
<div class="row">
<fieldset>
<legend>
Molecular monitoring of CML - request for RQ-PCR BCR-ABL estimation
</legend>
</fieldset>
</div>
<p class="row indent info">
<u>Important information</u>: this request form should only be used
for follow-up in typical CML patients with a confirmed b2a2 or b3a2
BCR-ABL breakpoint.<br />
Other breakpoints cannot be monitored by this technique. If in doubt,
contact HMDS.
</p>
<p class="row indent info">
New cases of suspected CML should use the standard HMDS request form:
<a href="[% request.uri_base %]"><img src="/images/request.jpg" /></a>
</p>
<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 %] -->