[% 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 &amp; 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 &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>
        <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>