sites/default/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: left;
  31 }
  32 .subhead {
  33  font-weight: bold;
  34  font-size: 8pt;
  35 }
  36 .under {
  37  border-style: solid;
  38  border-width: 0 0 1px 0;
  39  border-color: #999999;
  40 }
  41
  42 .ftitletable {
  43  width: 100%;
  44  margin: 0 0 0 0;
  45 }
  46 .ftitlecell1 {
  47  vertical-align: top;
  48  text-align: left;
  49  font-size: 14pt;
  50  font-weight: bold;
  51 }
  52 .ftitlecell2 {
  53  vertical-align: top;
  54  text-align: right;
  55  font-size: 9pt;
  56  padding-right: 10pt;
  57 }
  58 </style>
  59
  60 <title>{label_webpage_title}</title>
  61 </head>
  62
  63 <body bgcolor='#ffffff'>
  64
  65 <!-- The double div resolves a difference between Firefox and IE in treatment of padding. -->
  66 <div class='borderdiv'><div class='paddingdiv'>
  67
  68  <table cellspacing='0' cellpadding='0' class='bigtable'>
  69   <tr>
  70    <td class='mainhead' valign='top'>
  71     {header1}
  72     <span class='subhead'>{label_subhead_clinic}</span>
  73    </td>
  74    <td align='right' width='10%' valign='top' nowrap>
  75     <table border='1' cellpadding='2' cellspacing='0'>
  76      <tr>
  77       <td nowrap>{label_clinic_id}</td>
  78       <td style='width:60pt' nowrap>{fac_facility_npi}</td>
  79      </tr>
  80      <tr>
  81       <td nowrap>{label_clinic_id}</td>
  82       <td nowrap>{ref_pid}</td>
  83      </tr>
  84      <tr>
  85       <td nowrap>{label_control_no}</td>
  86       <td nowrap>{ref_id}</td>
  87      </tr>
  88      <tr>
  89       <td nowrap>{label_date}</td>
  90       <td nowrap>{ref_refer_date}&nbsp;</td>
  91      </tr>
  92     </table>
  93    </td>
  94   </tr>
  95  </table>
  96
  97  <table cellspacing='0' cellpadding='0' class='linetable'>
  98   <tr>
  99    <td width='1%' nowrap>{label_name} &nbsp;</td>
 100    <td class='under'>{pt_title} {pt_fname} {pt_mname} {pt_lname}&nbsp;</td>
 101    <td width='1%' nowrap>&nbsp; {label_age} &nbsp;</td>
 102    <td class='under'>{pt_age}&nbsp;</td>
 103    <td width='1%' nowrap>&nbsp; {label_gender} &nbsp;</td>
 104    <td class='under'>{pt_sex}&nbsp;</td>
 105   </tr>
 106  </table>
 107
 108  <table cellspacing='0' cellpadding='0' class='linetable'>
 109   <tr>
 110    <td width='1%' nowrap>{label_address} &nbsp;</td>
 111    <td class='under'>{pt_street}, {pt_city} {pt_state}&nbsp;</td>
 112    <td width='1%' nowrap>&nbsp; {label_postal} &nbsp;</td>
 113    <td class='under'>{pt_postal_code}&nbsp;</td>
 114    <td width='1%' nowrap>&nbsp; {label_phone} &nbsp;</td>
 115    <td class='under'>{pt_phone_home}&nbsp;</td>
 116   </tr>
 117  </table>
 118
 119  <table cellspacing='0' cellpadding='0' class='linetable'>
 120   <tr>
 121    <td width='1%' nowrap>{label_ref_reason} &nbsp;</td>
 122    <td class='under'>{ref_body}&nbsp;</td>
 123   </tr>
 124  </table>
 125
 126  <table cellspacing='0' cellpadding='0' class='linetable'>
 127   <tr>
 128    <td width='1%' nowrap>{label_diagnosis} &nbsp;</td>
 129    <td class='under'>{ref_refer_diag}&nbsp;</td>
 130   </tr>
 131  </table>
 132
 133  <table cellspacing='0' cellpadding='0' class='linetable'>
 134   <tr>
 135    <td width='1%' nowrap>{label_ref_class} &nbsp;</td>
 136    <td class='under'>{ref_refer_risk_level}&nbsp;</td>
 137   </tr>
 138  </table>
 139
 140  <table cellspacing='0' cellpadding='0' class='linetable'>
 141   <tr>
 142    <td width='1%' nowrap>{label_dr_name_sig} &nbsp;</td>
 143    <td class='under'>{ref_refer_from}&nbsp;</td>
 144   </tr>
 145  </table>
 146
 147  <table cellspacing='0' cellpadding='0' class='linetable'>
 148   <tr>
 149    <td width='1%' nowrap>{label_refer_to} &nbsp;</td>
 150    <td class='under'>{ref_refer_to} / {to_organization}&nbsp;</td>
 151   </tr>
 152  </table>
 153
 154  <hr style='border:0;height:6pt;color:#999999;background-color:#999999;margin:12pt 0 12pt 0;' />
 155
 156  <table cellspacing='0' cellpadding='0' class='bigtable'>
 157   <tr>
 158    <td class='mainhead' valign='top'>
 159     {header1}
 160     <span class='subhead'>{label_subhead_patient}</span>
 161    </td>
 162    <td align='right' width='10%' nowrap>
 163     <table border='1' cellpadding='2' cellspacing='0'>
 164      <tr>
 165       <td nowrap>{label_clinic_id}</td>
 166       <td style='width:60pt' nowrap>{fac_facility_npi}</td>
 167      </tr>
 168      <tr>
 169       <td nowrap>{label_clinic_id}</td>
 170       <td nowrap>{ref_pid}</td>
 171      </tr>
 172      <tr>
 173       <td nowrap>{label_control_no}</td>
 174       <td nowrap>{ref_id}</td>
 175      </tr>
 176      <tr>
 177       <td nowrap>{label_date}</td>
 178       <td nowrap>{ref_refer_date}&nbsp;</td>
 179      </tr>
 180     </table>
 181    </td>
 182   </tr>
 183  </table>
 184
 185  <table cellspacing='0' cellpadding='0' class='linetable'>
 186   <tr>
 187    <td width='1%' nowrap>{label_name} &nbsp;</td>
 188    <td class='under'>{pt_title} {pt_fname} {pt_mname} {pt_lname}&nbsp;</td>
 189    <td width='1%' nowrap>&nbsp; Age &nbsp;</td>
 190    <td class='under'>{pt_age}&nbsp;</td>
 191    <td width='1%' nowrap>&nbsp; {label_gender} &nbsp;</td>
 192    <td class='under'>{pt_sex}&nbsp;</td>
 193   </tr>
 194  </table>
 195
 196  <table cellspacing='0' cellpadding='0' class='linetable'>
 197   <tr>
 198    <td width='1%' nowrap>{label_clinic} &nbsp;</td>
 199    <td class='under'>{to_organization}&nbsp;</td>
 200   </tr>
 201  </table>
 202
 203  <table cellspacing='0' cellpadding='0' class='linetable'>
 204   <tr>
 205    <td width='1%' nowrap>{label_address} &nbsp;</td>
 206    <td class='under'>{to_street}, {to_city} {to_state}&nbsp;</td>
 207    <td width='1%' nowrap>&nbsp; {label_postal} &nbsp;</td>
 208    <td class='under'>{to_zip}&nbsp;</td>
 209    <td width='1%' nowrap>&nbsp; {label_phone} &nbsp;</td>
 210    <td class='under'>{to_phone}&nbsp;</td>
 211   </tr>
 212  </table>
 213
 214  <table cellspacing='0' cellpadding='0' class='linetable'>
 215   <tr>
 216    <td width='1%' nowrap>{label_ref_reason} &nbsp;</td>
 217    <td class='under'>{ref_body}&nbsp;</td>
 218   </tr>
 219  </table>
 220
 221  <br />&nbsp;<br />{label_history_summary}:
 222
 223  <table cellspacing='0' cellpadding='0' class='linetable'>
 224   <tr>
 225    <td width='1%' nowrap>{label_bp} &nbsp;</td>
 226    <td class='under'>{v_bps}/{v_bpd}&nbsp;</td>
 227    <td width='1%' nowrap>&nbsp; {label_ht} &nbsp;</td>
 228    <td class='under'>{v_height}&nbsp;</td>
 229    <td width='1%' nowrap>&nbsp; {label_wt} &nbsp;</td>
 230    <td class='under'>{v_weight}&nbsp;</td>
 231   </tr>
 232  </table>
 233
 234  <p>
 235
 236  <table cellspacing='0' cellpadding='0' class='linetable'>
 237   <tr>
 238    <td width='1%' nowrap>{label_ref_name_sig} &nbsp;</td>
 239    <td class='under'>{ref_refer_from}&nbsp;</td>
 240   </tr>
 241  </table>
 242
 243  <table cellspacing='0' cellpadding='0' class='linetable'>
 244   <tr>
 245    <td width='1%' nowrap>{label_special_name_sig} &nbsp;</td>
 246    <td class='under'>{ref_refer_to}&nbsp;</td>
 247   </tr>
 248  </table>
 249
 250 </div></div>
 251 <br clear='all' /><!-- kludge to fix bizarre Firefox problem with page breaks -->
 252 <p style='page-break-after: always' />
 253 <div class='borderdiv'><div class='paddingdiv'>
 254
 255  <table cellspacing='0' cellpadding='0' class='bigtable'>
 256   <tr>
 257    <td class='mainhead' valign='top'>
 258     {header2}
 259     <span class='subhead'>{label_subhead_referred}</span>
 260    </td>
 261    <td align='right' width='10%' nowrap>
 262     <table border='1' cellpadding='2' cellspacing='0'>
 263      <tr>
 264       <td nowrap>{label_clinic_id}</td>
 265       <td style='width:60pt' nowrap>{fac_facility_npi}</td>
 266      </tr>
 267      <tr>
 268       <td nowrap>{label_clinic_id}</td>
 269       <td nowrap>{ref_pid}</td>
 270      </tr>
 271      <tr>
 272       <td nowrap>{label_control_no}</td>
 273       <td nowrap>{ref_id}</td>
 274      </tr>
 275      <tr>
 276       <td nowrap>{label_date}</td>
 277       <td nowrap>{ref_reply_date}&nbsp;</td>
 278      </tr>
 279     </table>
 280    </td>
 281   </tr>
 282  </table>
 283
 284  <table cellspacing='0' cellpadding='0' class='linetable'>
 285   <tr>
 286    <td width='1%' nowrap>{label_name} &nbsp;</td>
 287    <td class='under'>{pt_title} {pt_fname} {pt_mname} {pt_lname}&nbsp;</td>
 288    <td width='1%' nowrap>&nbsp; {label_age} &nbsp;</td>
 289    <td class='under'>{pt_age}&nbsp;</td>
 290    <td width='1%' nowrap>&nbsp; {label_gender} &nbsp;</td>
 291    <td class='under'>{pt_sex}&nbsp;</td>
 292   </tr>
 293  </table>
 294
 295  <table cellspacing='0' cellpadding='0' class='linetable'>
 296   <tr>
 297    <td width='1%' nowrap>{label_clinic} &nbsp;</td>
 298    <td class='under'>{to_organization}&nbsp;</td>
 299   </tr>
 300  </table>
 301
 302  <table cellspacing='0' cellpadding='0' class='linetable'>
 303   <tr>
 304    <td width='1%' nowrap>{label_diagnosis} &nbsp;</td>
 305    <td class='under'>{ref_reply_init_diag}&nbsp;</td>
 306   </tr>
 307  </table>
 308
 309  <table cellspacing='0' cellpadding='0' class='linetable'>
 310   <tr>
 311    <td width='1%' nowrap>{label_findings} &nbsp;</td>
 312    <td class='under'>{ref_reply_findings}&nbsp;</td>
 313   </tr>
 314  </table>
 315
 316  <table cellspacing='0' cellpadding='0' class='linetable'>
 317   <tr>
 318    <td width='1%' nowrap>{label_final_diagnosis} &nbsp;</td>
 319    <td class='under'>{ref_reply_final_diag}&nbsp;</td>
 320   </tr>
 321  </table>
 322
 323  <table cellspacing='0' cellpadding='0' class='linetable'>
 324   <tr>
 325    <td width='1%' nowrap>{label_services_provided} &nbsp;</td>
 326    <td class='under'>{ref_reply_services}&nbsp;</td>
 327   </tr>
 328  </table>
 329
 330  <table cellspacing='0' cellpadding='0' class='linetable'>
 331   <tr>
 332    <td width='1%' nowrap>{label_recommendations} &nbsp;</td>
 333    <td class='under'>{ref_reply_recommend}&nbsp;</td>
 334   </tr>
 335  </table>
 336
 337  <table cellspacing='0' cellpadding='0' class='linetable'>
 338   <tr>
 339    <td width='1%' nowrap>{label_scripts_and_referrals} &nbsp;</td>
 340    <td class='under'>{ref_reply_rx_refer}&nbsp;</td>
 341   </tr>
 342  </table>
 343
 344  <table cellspacing='0' cellpadding='0' class='linetable'>
 345   <tr>
 346    <td width='1%' nowrap>{label_special_name_sig} &nbsp;</td>
 347    <td class='under'>{ref_refer_to}&nbsp;</td>
 348   </tr>
 349  </table>
 350
 351 </div></div>
 352
 353 <!-- This should really be in the onload handler but that seems to be unreliable and can crash Firefox 3. -->
 354 <script language='JavaScript'>
 355 window.print();
 356 </script>
 357
 358 </body>
 359 </html>