custom/referral_template.html

   1 <html>
   2 <head>
   3
   4 <style>
   5 body, td {
   6  font-family: sans-serif;
   7  font-weight: normal;
   8  font-size: 9pt;
   9 }
  10 .borderdiv {
  11  width: 524pt;
  12  height: 704pt;
  13  padding: 0;
  14  border-style: solid;
  15  border-width: 1px;
  16  border-color: #000000;
  17 }
  18 .paddingdiv {
  19  padding: 10pt;
  20 }
  21 .bigtable, .linetable {
  22  width: 504pt;
  23 }
  24 .linetable {
  25  margin: 11pt 0 0 0;
  26 }
  27 .mainhead {
  28  font-weight: bold;
  29  font-size: 14pt;
  30  text-align: center;
  31 }
  32 .under {
  33  border-style: solid;
  34  border-width: 0 0 1px 0;
  35  border-color: #999999;
  36 }
  37 </style>
  38
  39 <title>Referral Form</title>
  40 </head>
  41
  42 <body bgcolor='#ffffff' onload='window.print()'>
  43
  44 <!-- The double div resolves a difference between Firefox and IE in treatment of padding. -->
  45 <div class='borderdiv'><div class='paddingdiv'>
  46
  47  <table cellspacing='0' cellpadding='0' class='bigtable'>
  48   <tr>
  49    <td class='mainhead'>{fac_name}<br />&nbsp;</td>
  50    <td rowspan='2' align='right' width='10%' nowrap>
  51     <table border='1' cellpadding='2' cellspacing='0'>
  52      <tr>
  53       <td nowrap>Clinic ID</td>
  54       <td nowrap>{fac_facility_npi}</td>
  55      </tr>
  56      <tr>
  57       <td nowrap>Client ID</td>
  58       <td nowrap>{ref_pid}</td>
  59      </tr>
  60      <tr>
  61       <td nowrap>Control No.</td>
  62       <td nowrap>{ref_id}</td>
  63      </tr>
  64      <tr>
  65       <td nowrap>Date</td>
  66       <td nowrap>{ref_refer_date}</td>
  67      </tr>
  68     </table>
  69    </td>
  70   </tr>
  71   <tr>
  72    <td align='center' valign='top'><b>REFERRAL FORM</b></td>
  73   </tr>
  74  </table>
  75
  76  <table cellspacing='0' cellpadding='0' class='linetable'>
  77   <tr>
  78    <td width='1%' nowrap>Name &nbsp;</td>
  79    <td class='under'>{pt_title} {pt_fname} {pt_mname} {pt_lname}&nbsp;</td>
  80    <td width='1%' nowrap>&nbsp; Age &nbsp;</td>
  81    <td class='under'>{pt_age}&nbsp;</td>
  82    <td width='1%' nowrap>&nbsp; Gender &nbsp;</td>
  83    <td class='under'>{pt_sex}&nbsp;</td>
  84   </tr>
  85  </table>
  86
  87  <table cellspacing='0' cellpadding='0' class='linetable'>
  88   <tr>
  89    <td width='1%' nowrap>Address &nbsp;</td>
  90    <td class='under'>{pt_street}, {pt_city} {pt_state}&nbsp;</td>
  91    <td width='1%' nowrap>&nbsp; Postal &nbsp;</td>
  92    <td class='under'>{pt_postal_code}&nbsp;</td>
  93    <td width='1%' nowrap>&nbsp; Phone &nbsp;</td>
  94    <td class='under'>{pt_phone_home}&nbsp;</td>
  95   </tr>
  96  </table>
  97
  98  <table cellspacing='0' cellpadding='0' class='linetable'>
  99   <tr>
 100    <td width='1%' nowrap>Reference Reason &nbsp;</td>
 101    <td class='under'>{ref_body}&nbsp;</td>
 102   </tr>
 103  </table>
 104
 105  <table cellspacing='0' cellpadding='0' class='linetable'>
 106   <tr>
 107    <td width='1%' nowrap>Diagnosis &nbsp;</td>
 108    <td class='under'>{ref_refer_diag}&nbsp;</td>
 109   </tr>
 110  </table>
 111
 112  <table cellspacing='0' cellpadding='0' class='linetable'>
 113   <tr>
 114    <td width='1%' nowrap>Reference classification (risk level) &nbsp;</td>
 115    <td class='under'>{ref_refer_risk_level}&nbsp;</td>
 116   </tr>
 117  </table>
 118
 119  <table cellspacing='0' cellpadding='0' class='linetable'>
 120   <tr>
 121    <td width='1%' nowrap>Doctor's name and signature &nbsp;</td>
 122    <td class='under'>{ref_refer_from}&nbsp;</td>
 123   </tr>
 124  </table>
 125
 126  <table cellspacing='0' cellpadding='0' class='linetable'>
 127   <tr>
 128    <td width='1%' nowrap>Referred to &nbsp;</td>
 129    <td class='under'>{ref_refer_to} / {to_organization}&nbsp;</td>
 130   </tr>
 131  </table>
 132
 133  <hr style='border:0;height:6pt;color:#999999;background-color:#999999;margin:12pt 0 12pt 0;' />
 134
 135  <table cellspacing='0' cellpadding='0' class='bigtable'>
 136   <tr>
 137    <td class='mainhead'>{fac_name}<br />&nbsp;</td>
 138    <td rowspan='2' align='right' width='10%' nowrap>
 139     <table border='1' cellpadding='2' cellspacing='0'>
 140      <tr>
 141       <td nowrap>Clinic ID</td>
 142       <td nowrap>{fac_facility_npi}</td>
 143      </tr>
 144      <tr>
 145       <td nowrap>Client ID</td>
 146       <td nowrap>{ref_pid}</td>
 147      </tr>
 148      <tr>
 149       <td nowrap>Control No.</td>
 150       <td nowrap>{ref_id}</td>
 151      </tr>
 152      <tr>
 153       <td nowrap>Date</td>
 154       <td nowrap>{ref_refer_date}</td>
 155      </tr>
 156     </table>
 157    </td>
 158   </tr>
 159   <tr>
 160    <td align='center' valign='top'>&nbsp;</td>
 161   </tr>
 162  </table>
 163
 164  <table cellspacing='0' cellpadding='0' class='linetable'>
 165   <tr>
 166    <td width='1%' nowrap>Name &nbsp;</td>
 167    <td class='under'>{pt_title} {pt_fname} {pt_mname} {pt_lname}&nbsp;</td>
 168    <td width='1%' nowrap>&nbsp; Age &nbsp;</td>
 169    <td class='under'>{pt_age}&nbsp;</td>
 170    <td width='1%' nowrap>&nbsp; Gender &nbsp;</td>
 171    <td class='under'>{pt_sex}&nbsp;</td>
 172   </tr>
 173  </table>
 174
 175  <table cellspacing='0' cellpadding='0' class='linetable'>
 176   <tr>
 177    <td width='1%' nowrap>Health centre/clinic &nbsp;</td>
 178    <td class='under'>{to_organization}&nbsp;</td>
 179   </tr>
 180  </table>
 181
 182  <table cellspacing='0' cellpadding='0' class='linetable'>
 183   <tr>
 184    <td width='1%' nowrap>Address &nbsp;</td>
 185    <td class='under'>{to_street}, {to_city} {to_state}&nbsp;</td>
 186    <td width='1%' nowrap>&nbsp; Postal &nbsp;</td>
 187    <td class='under'>{to_zip}&nbsp;</td>
 188    <td width='1%' nowrap>&nbsp; Phone &nbsp;</td>
 189    <td class='under'>{to_phone}&nbsp;</td>
 190   </tr>
 191  </table>
 192
 193  <table cellspacing='0' cellpadding='0' class='linetable'>
 194   <tr>
 195    <td width='1%' nowrap>Reference Reason &nbsp;</td>
 196    <td class='under'>{ref_body}&nbsp;</td>
 197   </tr>
 198  </table>
 199
 200  <br />&nbsp;<br />Client medical history summary:
 201
 202  <table cellspacing='0' cellpadding='0' class='linetable'>
 203   <tr>
 204    <td width='1%' nowrap>Blood pressure &nbsp;</td>
 205    <td class='under'>{v_bps}/{v_bpd}&nbsp;</td>
 206    <td width='1%' nowrap>&nbsp; Height &nbsp;</td>
 207    <td class='under'>{v_height}&nbsp;</td>
 208    <td width='1%' nowrap>&nbsp; Weight &nbsp;</td>
 209    <td class='under'>{v_weight}&nbsp;</td>
 210   </tr>
 211  </table>
 212
 213  <p>
 214
 215  <table cellspacing='0' cellpadding='0' class='linetable'>
 216   <tr>
 217    <td width='1%' nowrap>Referer name and signature &nbsp;</td>
 218    <td class='under'>{ref_refer_from}&nbsp;</td>
 219   </tr>
 220  </table>
 221
 222  <table cellspacing='0' cellpadding='0' class='linetable'>
 223   <tr>
 224    <td width='1%' nowrap>Specialist name and signature &nbsp;</td>
 225    <td class='under'>{ref_refer_to}&nbsp;</td>
 226   </tr>
 227  </table>
 228
 229 </div></div>
 230
 231 <div class='borderdiv' style='page-break-before:always;'><div class='paddingdiv'>
 232
 233  <table cellspacing='0' cellpadding='0' class='bigtable'>
 234   <tr>
 235    <td class='mainhead'>{fac_name}<br />&nbsp;</td>
 236    <td rowspan='2' align='right' width='10%' nowrap>
 237     <table border='1' cellpadding='2' cellspacing='0'>
 238      <tr>
 239       <td nowrap>Clinic ID</td>
 240       <td nowrap>{fac_facility_npi}</td>
 241      </tr>
 242      <tr>
 243       <td nowrap>Client ID</td>
 244       <td nowrap>{ref_pid}</td>
 245      </tr>
 246      <tr>
 247       <td nowrap>Control No.</td>
 248       <td nowrap>{ref_id}</td>
 249      </tr>
 250      <tr>
 251       <td nowrap>Date</td>
 252       <td nowrap>{ref_reply_date}&nbsp;</td>
 253      </tr>
 254     </table>
 255    </td>
 256   </tr>
 257   <tr>
 258    <td align='center' valign='top'><b>CONTRA REFERENCE SHEET</b></td>
 259   </tr>
 260  </table>
 261
 262  <table cellspacing='0' cellpadding='0' class='linetable'>
 263   <tr>
 264    <td width='1%' nowrap>Name &nbsp;</td>
 265    <td class='under'>{pt_title} {pt_fname} {pt_mname} {pt_lname}&nbsp;</td>
 266    <td width='1%' nowrap>&nbsp; Age &nbsp;</td>
 267    <td class='under'>{pt_age}&nbsp;</td>
 268    <td width='1%' nowrap>&nbsp; Gender &nbsp;</td>
 269    <td class='under'>{pt_sex}&nbsp;</td>
 270   </tr>
 271  </table>
 272
 273  <table cellspacing='0' cellpadding='0' class='linetable'>
 274   <tr>
 275    <td width='1%' nowrap>Health centre/clinic &nbsp;</td>
 276    <td class='under'>{to_organization}&nbsp;</td>
 277   </tr>
 278  </table>
 279
 280  <table cellspacing='0' cellpadding='0' class='linetable'>
 281   <tr>
 282    <td width='1%' nowrap>Diagnosis &nbsp;</td>
 283    <td class='under'>{ref_reply_init_diag}&nbsp;</td>
 284   </tr>
 285  </table>
 286
 287  <table cellspacing='0' cellpadding='0' class='linetable'>
 288   <tr>
 289    <td width='1%' nowrap>Findings &nbsp;</td>
 290    <td class='under'>{ref_reply_findings}&nbsp;</td>
 291   </tr>
 292  </table>
 293
 294  <table cellspacing='0' cellpadding='0' class='linetable'>
 295   <tr>
 296    <td width='1%' nowrap>Final Diagnosis &nbsp;</td>
 297    <td class='under'>{ref_reply_final_diag}&nbsp;</td>
 298   </tr>
 299  </table>
 300
 301  <table cellspacing='0' cellpadding='0' class='linetable'>
 302   <tr>
 303    <td width='1%' nowrap>Services provided &nbsp;</td>
 304    <td class='under'>{ref_reply_services}&nbsp;</td>
 305   </tr>
 306  </table>
 307
 308  <table cellspacing='0' cellpadding='0' class='linetable'>
 309   <tr>
 310    <td width='1%' nowrap>Recommendations and treatment &nbsp;</td>
 311    <td class='under'>{ref_reply_recommend}&nbsp;</td>
 312   </tr>
 313  </table>
 314
 315  <table cellspacing='0' cellpadding='0' class='linetable'>
 316   <tr>
 317    <td width='1%' nowrap>Prescriptions and other referrals &nbsp;</td>
 318    <td class='under'>{ref_reply_rx_refer}&nbsp;</td>
 319   </tr>
 320  </table>
 321
 322  <table cellspacing='0' cellpadding='0' class='linetable'>
 323   <tr>
 324    <td width='1%' nowrap>Specialist name and signature &nbsp;</td>
 325    <td class='under'>{ref_refer_to}&nbsp;</td>
 326   </tr>
 327  </table>
 328
 329 </div></div>
 330
 331 </body>
 332 </html>