[% PROCESS headers.tt; # sets header
# INCLUDE dumper.tt dump = header;
# INCLUDE dumper.tt dump = data;
# INCLUDE dumper.tt dump = data.treatment_date; # only submitted if NOT 1st-line tx
# INCLUDE dumper.tt dump = data.first_line_date; # always submitted
%]
<div class="container" id="pdf">
<div class="row">
<img src="[% request.uri_base %]/images/[% header.logos.small %]"
alt="" border="0" class="img-responsive" />
</div>
<div class="row">
<h4 class="text-primary text-center">
[% header.title %] Request Form
</h4>
</div>
<div class="row">
<div style="display: inline-block; padding: 0 20px;">
[% # need to adjust td.hbc_off & td.hbc_on px heights:
data.qrcode.replace('hbc_(on|off)', 'hbq_$1') %]
</div>
<div style="display: inline-block; vertical-align: top">
<div class="strong">
[% header.addr1 %]<br />[% header.addr2 %]<br />[% header.addr3 %]
</div>
<div class="text-center" style="padding: 10px 25px">
[% data.barcode %]
</div>
</div>
</div>
[% IF params.bcr_abl_req %]
<div class="row">
<div class="text-center">
<h3>HMDS BCR-ABL Monitoring Request Form</h3>
</div>
</div>
[% END %]
<div class="row">
<div class="col-md-offset-1 text-uppercase text-center">
<p class="text-danger bg-danger">
PLEASE ATTACH DOI STICKERS FOR HIGH-RISK SAMPLES
</p>
</div>
</div>
<div class="row" id="details">
<div class="col-md-6">
<table class="table">
<tr>
<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>
<span class="text-capitalize">[% data.middle_name %]</span>
</td>
</tr>
<tr>
<td>
<span class="fieldname">NHS number:</span>
<span class="normal">
[% data.nhs_number.match('(\d{3})(\d{3})(\d{4})').join %]
</span>
</td>
<td><span class="fieldname">Patient/unit number:</span>
<span class="normal">[% data.patient_number %]</span>
</td>
</tr>
<tr>
<td><span class="fieldname">DoB:</span>
<span class="">[% data.dob.dmy %]</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_name %]</span>
</td>
<td><span class="fieldname">Consultant:</span>
<span class="text-capitalize">[% data.referrer %]</span>
</td>
</tr>
<tr>
<td>
<div>
<span class="fieldname">Danger of infection:</span>
[% class = data.doi.match('YES')
? 'btn btn-danger btn-xs' : 'normal' %]
<span class="[% class %]">[% data.doi %]</span>
</div>
<div>
<span class="fieldname">Evidence of TB:</span>
[% class = data.tb.match('YES')
? 'btn btn-danger btn-xs' : 'normal' %]
<span class="[% class %]">[% data.tb %]</span>
</div>
</td>
<td>
<span class="fieldname">Previously investigated:</span>
<span class="normal">[% data.previous %]</span>
</td>
</tr>
<tr>
<td colspan="2">
<span class="fieldname">Specimen type(s):</span>
<span class="normal">[% data.specimen %]</span>
</td>
</tr>
</table>
<table class="table">
<tr>
<td colspan="2">
<span class="fieldname">Sample ref:</span>
<span class="normal">[% data.sample_ref %]</span>
</td>
<td rowspan="3">
<table class="table-condensed borderless">
<tr>
<td>
<span class="fieldname">Hb:</span>
<span class="normal">[% data.hb %]</span>
</td>
<td>
<span class="fieldname">Lymph:</span>
<span class="normal">[% data.lymph %]</span>
</td>
</tr>
<tr>
<td>
<span class="fieldname">WBC:</span>
<span class="normal">[% data.wbc %]</span>
</td>
<td>
<span class="fieldname">Neut:</span>
<span class="normal">[% data.neut %]</span>
</td>
</tr>
<tr>
<td>
<span class="fieldname">Plts:</span>
<span class="normal">[% data.plt %]</span>
</td>
<td>
<span class="fieldname">Other:</span>
<span class="normal">[% data.other %]</span>
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td colspan="2">
<span class="fieldname">Return report to:</span>
<span class="text-capitalize">[% data.report_to %]</span>
</td>
</tr>
[% IF params.bcr_abl_req %]
<tr>
<td colspan="3">
<span class="fieldname">Date of diagnosis:</span>
<span class="normal">[% data.diagnosis_date %]</span>
</td>
</tr>
<tr>
<td colspan="3">
<span class="fieldname">Phase of disease:</span>
<span class="normal">[% data.phase %]</span>
</td>
</tr>
<tr>
<td colspan="3">
<span class="fieldname">Current treatment details:</span>
<span class="normal">
[% data.line_num %] [% data.treatment %] commenced
[%# treatment_date only supplied if NOT 1st-line,
first_line_date should always be supplied: %]
[% data.treatment_date || data.first_line_date %]
</span>
</td>
</tr>
[% IF data.reason %]
<tr>
<td colspan="3">
<span class="fieldname">Reason for request:</span>
<span class="highlight">**</span>
<span class="normal">[% data.reason %]</span>
<span class="highlight">**</span>
</td>
</tr>
[% END %]
[% ELSE %]
<tr>
<td colspan="3">
<span class="fieldname">Recent chemo/radiotherapy
details:</span>
<span class="normal">[% data.treatment %]</span>
</td>
</tr>
<tr>
<td colspan="3">
<span class="fieldname">Clinical details:</span>
<span class="normal">[% data.clinical_details %]</span>
</td>
</tr>
[% END %]
<tr>
<td colspan="2">
<span class="fieldname">Requested by:</span>
<span class="text-capitalize">[% data.requested_by %]</span>
on [% USE date = DateTime(today = 1); date.dmy('.') %]
</td>
<td>
<span class="fieldname">Contact details:</span>
<span class="normal">[% data.contact %]</span>
</td>
</tr>
<tr>
<td colspan="3"></td>
</tr>
<tr id="manualFill">
<td colspan="2">
<span class="fieldname">Specimen taken by:</span>
[% # data.taken_by # now filled in on PDF %]
<span class="grey"> PLEASE COMPLETE THIS SECTION</span>
</td>
<td>
<span class="fieldname">Date & time:</span>
[% # data.datetime # now filled in on PDF %]
</td>
</tr>
<tr>
<td colspan="3">
<div class="text-danger bg-danger" align="center">
Please telephone department if urgent result is required
</div>
</td>
</tr>
</table>
</div>
</div>
<div id="box">
<div class="row">
<div class="strong" align="center">For Laboratory Use Only</div>
</div>
<div class="row section">
<div class="col-md-8 col-md-offset-1">
<table width="100%">
<tr>
<td width="50%">Date & time:</td>
<td width="25%">Initials:</td>
<td width="25%">[% header.lab_name %] Error Code:</td>
</tr>
<tr>
<td colspan="3">
<div class="pull-right">
PDS Code: [% params.pds_code %]
</div>
</td>
</tr>
</table>
</div>
</div>
<div class="row section">
<div class="col-md-8 col-md-offset-1">
<u>Gross description / contents:</u>
</div>
</div>
<div class="row section">
<div class="indent">
........ core of tissue ....... mm in length
</div>
</div>
<div id="ver">App version: [% vars.app_version %]</div>
</div>
</div>