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<!-- 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>
-->
    <h4 class="text-info">
      1) Request is for a CML patient with a confirmed b2a2 or b3a2 BCR-ABL breakpoint:
      <a href="#" id="cml-patient"><i class="fa fa-folder-open-o"></i></a>
    </h4>

    <div id="for-cml-patient" class="indent" [% # auto-open if form submission:
      UNLESS params.nhs_number # 'u' & 'c' always %]style="display: none"[% END %]>
      <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>

  <h4 class="text-info">
    2) Request is for a suspected CML, or confirmed CML with other BCR-ABL breakpoint:
    <a href="#" id="new-patient"><i class="fa fa-folder-open-o"></i></a>
  </h4>
  <div id="for-new-patient" style="display: none;">
    <p class="text-warning indent">
      Please use the standard HMDS request form:
      <a href="[% request.uri_base %]"><img src="/images/request.jpg" /></a>
    </p>
  </div>

    [% INCLUDE nhs_number_ajax.tt %]
      <script type="text/javascript">
        $('#cml-patient').click(function() {
            $('#for-cml-patient').slideToggle('fast', function() {
                // ok
            });
            return false;
        });
        $('#new-patient').click(function() {
            $('#for-new-patient').slideToggle('fast', function() {
                // ok
            });
            return false;
        });
    </script>

<!-- END [% template.name %] -->