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: 668pt;
  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>{label_webpage_title}</title>
  40 </head>
  41
  42 <body bgcolor='#ffffff'>
  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>{label_clinic_id}</td>
  54       <td style='width:60pt' nowrap>{fac_facility_npi}</td>
  55      </tr>
  56      <tr>
  57       <td nowrap>{label_clinic_id}</td>
  58       <td nowrap>{ref_pid}</td>
  59      </tr>
  60      <tr>
  61       <td nowrap>{label_control_no}</td>
  62       <td nowrap>{ref_id}</td>
  63      </tr>
  64      <tr>
  65       <td nowrap>{label_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>{label_form1_title}</b></td>
  73   </tr>
  74  </table>
  75
  76  <table cellspacing='0' cellpadding='0' class='linetable'>
  77   <tr>
  78    <td width='1%' nowrap>{label_name} &nbsp;</td>
  79    <td class='under'>{pt_title} {pt_fname} {pt_mname} {pt_lname}&nbsp;</td>
  80    <td width='1%' nowrap>&nbsp; {label_age} &nbsp;</td>
  81    <td class='under'>{pt_age}&nbsp;</td>
  82    <td width='1%' nowrap>&nbsp; {label_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>{label_address} &nbsp;</td>
  90    <td class='under'>{pt_street}, {pt_city} {pt_state}&nbsp;</td>
  91    <td width='1%' nowrap>&nbsp; {label_postal} &nbsp;</td>
  92    <td class='under'>{pt_postal_code}&nbsp;</td>
  93    <td width='1%' nowrap>&nbsp; {label_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>{label_ref_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>{label_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>{label_ref_class} &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>{label_dr_name_sig} &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>{label_refer_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>{label_clinic_id}</td>
 142       <td style='width:60pt' nowrap>{fac_facility_npi}</td>
 143      </tr>
 144      <tr>
 145       <td nowrap>{label_clinic_id}</td>
 146       <td nowrap>{ref_pid}</td>
 147      </tr>
 148      <tr>
 149       <td nowrap>{label_control_no}</td>
 150       <td nowrap>{ref_id}</td>
 151      </tr>
 152      <tr>
 153       <td nowrap>{label_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>{label_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; {label_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>{label_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>{label_address} &nbsp;</td>
 185    <td class='under'>{to_street}, {to_city} {to_state}&nbsp;</td>
 186    <td width='1%' nowrap>&nbsp; {label_postal} &nbsp;</td>
 187    <td class='under'>{to_zip}&nbsp;</td>
 188    <td width='1%' nowrap>&nbsp; {label_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>{label_ref_reason} &nbsp;</td>
 196    <td class='under'>{ref_body}&nbsp;</td>
 197   </tr>
 198  </table>
 199
 200  <br />&nbsp;<br />{label_history_summary}:
 201
 202  <table cellspacing='0' cellpadding='0' class='linetable'>
 203   <tr>
 204    <td width='1%' nowrap>{label_bp} &nbsp;</td>
 205    <td class='under'>{v_bps}/{v_bpd}&nbsp;</td>
 206    <td width='1%' nowrap>&nbsp; {label_ht} &nbsp;</td>
 207    <td class='under'>{v_height}&nbsp;</td>
 208    <td width='1%' nowrap>&nbsp; {label_wt} &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>{label_ref_name_sig} &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>{label_special_name_sig} &nbsp;</td>
 225    <td class='under'>{ref_refer_to}&nbsp;</td>
 226   </tr>
 227  </table>
 228
 229 </div></div>
 230 <br clear='all' /><!-- kludge to fix bizarre Firefox problem with page breaks -->
 231 <p style='page-break-after: always' />
 232 <div class='borderdiv'><div class='paddingdiv'>
 233
 234  <table cellspacing='0' cellpadding='0' class='bigtable'>
 235   <tr>
 236    <td class='mainhead'>{fac_name}<br />&nbsp;</td>
 237    <td rowspan='2' align='right' width='10%' nowrap>
 238     <table border='1' cellpadding='2' cellspacing='0'>
 239      <tr>
 240       <td nowrap>{label_clinic_id}</td>
 241       <td style='width:60pt' nowrap>{fac_facility_npi}</td>
 242      </tr>
 243      <tr>
 244       <td nowrap>{label_clinic_id}</td>
 245       <td nowrap>{ref_pid}</td>
 246      </tr>
 247      <tr>
 248       <td nowrap>{label_control_no}</td>
 249       <td nowrap>{ref_id}</td>
 250      </tr>
 251      <tr>
 252       <td nowrap>{label_date}</td>
 253       <td nowrap>{ref_reply_date}&nbsp;</td>
 254      </tr>
 255     </table>
 256    </td>
 257   </tr>
 258   <tr>
 259    <td align='center' valign='top'><b>{label_form2_title}</b></td>
 260   </tr>
 261  </table>
 262
 263  <table cellspacing='0' cellpadding='0' class='linetable'>
 264   <tr>
 265    <td width='1%' nowrap>{label_name} &nbsp;</td>
 266    <td class='under'>{pt_title} {pt_fname} {pt_mname} {pt_lname}&nbsp;</td>
 267    <td width='1%' nowrap>&nbsp; {label_age} &nbsp;</td>
 268    <td class='under'>{pt_age}&nbsp;</td>
 269    <td width='1%' nowrap>&nbsp; {label_gender} &nbsp;</td>
 270    <td class='under'>{pt_sex}&nbsp;</td>
 271   </tr>
 272  </table>
 273
 274  <table cellspacing='0' cellpadding='0' class='linetable'>
 275   <tr>
 276    <td width='1%' nowrap>{label_clinic} &nbsp;</td>
 277    <td class='under'>{to_organization}&nbsp;</td>
 278   </tr>
 279  </table>
 280
 281  <table cellspacing='0' cellpadding='0' class='linetable'>
 282   <tr>
 283    <td width='1%' nowrap>{label_diagnosis} &nbsp;</td>
 284    <td class='under'>{ref_reply_init_diag}&nbsp;</td>
 285   </tr>
 286  </table>
 287
 288  <table cellspacing='0' cellpadding='0' class='linetable'>
 289   <tr>
 290    <td width='1%' nowrap>{label_findings} &nbsp;</td>
 291    <td class='under'>{ref_reply_findings}&nbsp;</td>
 292   </tr>
 293  </table>
 294
 295  <table cellspacing='0' cellpadding='0' class='linetable'>
 296   <tr>
 297    <td width='1%' nowrap>{label_final_diagnosis} &nbsp;</td>
 298    <td class='under'>{ref_reply_final_diag}&nbsp;</td>
 299   </tr>
 300  </table>
 301
 302  <table cellspacing='0' cellpadding='0' class='linetable'>
 303   <tr>
 304    <td width='1%' nowrap>{label_services_provided} &nbsp;</td>
 305    <td class='under'>{ref_reply_services}&nbsp;</td>
 306   </tr>
 307  </table>
 308
 309  <table cellspacing='0' cellpadding='0' class='linetable'>
 310   <tr>
 311    <td width='1%' nowrap>{label_recommendations} &nbsp;</td>
 312    <td class='under'>{ref_reply_recommend}&nbsp;</td>
 313   </tr>
 314  </table>
 315
 316  <table cellspacing='0' cellpadding='0' class='linetable'>
 317   <tr>
 318    <td width='1%' nowrap>{label_scripts_and_referrals} &nbsp;</td>
 319    <td class='under'>{ref_reply_rx_refer}&nbsp;</td>
 320   </tr>
 321  </table>
 322
 323  <table cellspacing='0' cellpadding='0' class='linetable'>
 324   <tr>
 325    <td width='1%' nowrap>{label_special_name_sig} &nbsp;</td>
 326    <td class='under'>{ref_refer_to}&nbsp;</td>
 327   </tr>
 328  </table>
 329
 330 </div></div>
 331
 332 <!-- This should really be in the onload handler but that seems to be unreliable and can crash Firefox 3. -->
 333 <script language='JavaScript'>
 334 window.print();
 335 </script>
 336
 337 </body>
 338 </html>