[% 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 || data.referrer # report_to optional %]
						</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_number %] [% 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">&nbsp;&nbsp;PLEASE COMPLETE THIS SECTION</span>
                    </td>
                    <td>
                        <span class="fieldname">Date &amp; 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 &amp; 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>
		[% UNLESS params.bcr_abl_req %]
        <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>
		[% END %]
        <div id="ver">App version: [% app_version %]</div>
    </div>
  </div>