[% PROCESS headers.tt; # sets header
# INCLUDE dumper.tt dump = header %]
<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 class="text-center">
<strong>
[% header.addr1 %]<br />[% header.addr2 %]<br />[% header.addr3 %]
</strong>
</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 centered">
<table width="90%">
<tr>
<td>[% data.barcode %]</td>
<td align="right">[% # need to adjust td.hbc_off & td.hbc_on px heights:
data.qrcode.replace('hbc_(on|off)', 'hbq_$1') %]</td>
</tr>
</table>
</div>
<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">
<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>
[% data.nhs_number.match('(\d{3})(\d{3})(\d{4})').join %]
</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>
[% data.previous %]
</td>
</tr>
<tr>
<td colspan="2">
<span class="fieldname">Specimen type(s):</span>
[% data.specimen %]
</td>
</tr>
</table>
</div>
</div>
<div class="row">
<div class="col-md-6">
<table class="table">
<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">Lymph:</span> [% data.lymph %]</td>
</tr>
<tr>
<td><span class="fieldname">WBC:</span> [% data.wbc %]</td>
<td><span class="fieldname">Neut:</span> [% data.neut %]</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>
<!-- // combined with clinical_details
<tr>
<td colspan="2">
<span class="fieldname">Suspected diagnosis:</span>
[% data.diagnosis %]
</td>
</tr>
-->
<tr>
<td colspan="2">
<span class="fieldname">Return report to:</span>
[% data.report_to %]
</td>
</tr>
[% IF params.bcr_abl_req %]
<tr>
<td colspan="3">
<span class="fieldname">Month/year of diagnosis:</span>
[% data.diagnosis_date %]
</td>
</tr>
<tr>
<td colspan="3">
<span class="fieldname">Phase of disease:</span>
[% data.phase %]
</td>
</tr>
<tr>
<td colspan="3">
<span class="fieldname">Current treatment details:</span>
[% data.line_num %] [% data.treatment %] commenced
[% data.treatment_date %]
</td>
</tr>
[% IF data.reason %]
<tr>
<td colspan="3">
<span class="fieldname">Reason for request:</span>
<span class="highlight">**</span> [% data.reason %]
<span class="highlight">**</span>
</td>
</tr>
[% END %]
[% ELSE %]
<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>
[% END %]
<tr>
<td>
<span class="fieldname">Requested by:</span>
[% data.requested_by %]
</td>
<td>
<span class="fieldname">Contact details:</span>
[% data.contact %]
</td>
<td>
<span class="fieldname">Date:</span>
[% USE date = DateTime(today = 1); date.dmy %]
</td>
</tr>
<tr>
<td colspan="2">
<span class="fieldname">Specimen taken by:</span>
[% data.taken_by %]
</td>
<td>
<span class="fieldname">Date & time:</span>
[% data.datetime %]
</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>
</div>