sites/default/referral_template.html

   1 <!DOCTYPE html>
   2 <html>
   3 <head>
   4   <meta http-equiv="content-type" content="text/html; charset=UTF-8">
   5   <title>{label_webpage_title}</title>
   6   <style type="text/css">
   7     body, td {
   8       font-family: sans-serif;
   9       font-weight: normal;
  10       font-size: 9pt;
  11       background-color: #fff;
  12     }
  13     .borderdiv {
  14       width: 524pt;
  15       height: 668pt;
  16       padding: 0;
  17       border-style: solid;
  18       border-width: 1px;
  19       border-color: #000000;
  20     }
  21     .paddingdiv {
  22       padding: 10pt;
  23     }
  24     .bigtable{
  25       padding: 0px;
  26       border-spacing: 0;
  27       border-collapse: collapse;
  28     }
  29     .bigtable, .linetable {
  30       width: 504pt;
  31     }
  32     .linetable {
  33       margin: 11pt 0 0 0;
  34       padding: 0px;
  35       border-spacing: 0;
  36       border-collapse: collapse;
  37     }
  38     .mainhead {
  39       font-weight: bold;
  40       font-size: 14pt;
  41       text-align: left;
  42     }
  43     .subhead {
  44       font-weight: bold;
  45       font-size: 8pt;
  46     }
  47     .under {
  48       border-style: solid;
  49       border-width: 0 0 1px 0;
  50       border-color: #999999;
  51     }
  52     .ftitletable {
  53       width: 100%;
  54       margin: 0 0 0 0;
  55     }
  56     .ftitlecell1 {
  57       vertical-align: top;
  58       text-align: left;
  59       font-size: 14pt;
  60       font-weight: bold;
  61     }
  62     .ftitlecell2 {
  63       vertical-align: top;
  64       text-align: right;
  65       font-size: 9pt;
  66       padding-right: 10pt;
  67     }
  68     hr {
  69       border: 0;
  70       height: 6pt;
  71       color: #999999;
  72       background-color: #999999;
  73       margin: 12pt 0 12pt 0;
  74     }
  75     .tdLabelContainer {
  76       text-align: right;
  77       width: 10%;
  78       vertical-align: top;
  79       white-space: nowrap;
  80     }
  81     .mainhead {
  82       vertical-align: top;
  83     }
  84   </style>
  85 </head>
  86
  87 <body>
  88
  89 <!-- The double div resolves a difference between Firefox and IE in treatment of padding. -->
  90 <div class='borderdiv'><div class='paddingdiv'>
  91
  92  <table class="bigtable">
  93   <tr>
  94    <td class='mainhead' style="vertical-align:top">
  95     {header1}
  96     <span class='subhead'>{label_subhead_clinic}</span>
  97    </td>
  98    <td style="text-align:right;width:10%;white-space:nowrap">
  99     <table border='1' style="padding:2px;border-spacing:0;border-collapse:collapse">
 100      <tr>
 101       <td style="white-space:nowrap">{label_clinic_id}</td>
 102       <td style='width:60pt;white-space:nowrap'>{fac_facility_npi}</td>
 103      </tr>
 104      <tr>
 105       <td style="white-space:nowrap">{label_clinic_id}</td>
 106       <td style="white-space:nowrap">{ref_pid}</td>
 107      </tr>
 108      <tr>
 109       <td style="white-space:nowrap">{label_control_no}</td>
 110       <td style="white-space:nowrap">{ref_id}</td>
 111      </tr>
 112      <tr>
 113       <td style="white-space:nowrap">{label_date}</td>
 114       <td style="white-space:nowrap">{ref_refer_date}&nbsp;</td>
 115      </tr>
 116     </table>
 117    </td>
 118   </tr>
 119  </table>
 120
 121  <table class='linetable'>
 122   <tr>
 123    <td style="width:1%;white-space:nowrap">{label_name} &nbsp;</td>
 124    <td class='under'>{pt_title} {pt_fname} {pt_mname} {pt_lname}&nbsp;</td>
 125    <td style="width:1%;white-space:nowrap">&nbsp; {label_age} &nbsp;</td>
 126    <td class='under'>{pt_age}&nbsp;</td>
 127    <td style="width:1%;white-space:nowrap">&nbsp; {label_gender} &nbsp;</td>
 128    <td class='under'>{pt_sex}&nbsp;</td>
 129   </tr>
 130  </table>
 131
 132  <table class='linetable'>
 133   <tr>
 134    <td style="width:1%;white-space:nowrap">{label_address} &nbsp;</td>
 135    <td class='under'>{pt_street}, {pt_city} {pt_state}&nbsp;</td>
 136    <td style="width:1%;white-space:nowrap">&nbsp; {label_postal} &nbsp;</td>
 137    <td class='under'>{pt_postal_code}&nbsp;</td>
 138    <td style="width:1%;white-space:nowrap">&nbsp; {label_phone} &nbsp;</td>
 139    <td class='under'>{pt_phone_home}&nbsp;</td>
 140   </tr>
 141  </table>
 142
 143  <table class='linetable'>
 144   <tr>
 145    <td style="width:1%;white-space:nowrap">{label_ref_reason} &nbsp;</td>
 146    <td class='under'>{ref_body}&nbsp;</td>
 147   </tr>
 148  </table>
 149
 150  <table class='linetable'>
 151   <tr>
 152    <td style="width:1%;white-space:nowrap">{label_diagnosis} &nbsp;</td>
 153    <td class='under'>{ref_refer_diag}&nbsp;</td>
 154   </tr>
 155  </table>
 156
 157  <table class='linetable'>
 158   <tr>
 159    <td style="width:1%;white-space:nowrap">{label_ref_class} &nbsp;</td>
 160    <td class='under'>{ref_refer_risk_level}&nbsp;</td>
 161   </tr>
 162  </table>
 163
 164  <table class='linetable'>
 165   <tr>
 166    <td style="width:1%;white-space:nowrap">{label_dr_name_sig} &nbsp;</td>
 167    <td class='under'>{ref_refer_from}&nbsp;</td>
 168   </tr>
 169  </table>
 170
 171  <table class='linetable'>
 172   <tr>
 173    <td style="width:1%;white-space:nowrap">{label_refer_to} &nbsp;</td>
 174    <td class='under'>{ref_refer_to} / {to_organization}&nbsp;</td>
 175   </tr>
 176  </table>
 177
 178  <hr />
 179
 180  <table class="bigtable">
 181   <tr>
 182    <td class='mainhead'>
 183     {header1}
 184     <span class='subhead'>{label_subhead_patient}</span>
 185    </td>
 186    <td style="text-align:right;width:10%;white-space:nowrap">
 187     <table border='1' style="padding:2px;border-spacing:0;border-collapse:collapse">
 188      <tr>
 189       <td style="white-space:nowrap">{label_clinic_id}</td>
 190       <td style='width:60pt;white-space:nowrap'>{fac_facility_npi}</td>
 191      </tr>
 192      <tr>
 193       <td style="white-space:nowrap">{label_clinic_id}</td>
 194       <td style="white-space:nowrap">{ref_pid}</td>
 195      </tr>
 196      <tr>
 197       <td style="white-space:nowrap">{label_control_no}</td>
 198       <td style="white-space:nowrap">{ref_id}</td>
 199      </tr>
 200      <tr>
 201       <td style="white-space:nowrap">{label_date}</td>
 202       <td style="white-space:nowrap">{ref_refer_date}&nbsp;</td>
 203      </tr>
 204     </table>
 205    </td>
 206   </tr>
 207  </table>
 208
 209  <table class='linetable'>
 210   <tr>
 211    <td style="width:1%;white-space:nowrap">{label_name} &nbsp;</td>
 212    <td class='under'>{pt_title} {pt_fname} {pt_mname} {pt_lname}&nbsp;</td>
 213    <td style="width:1%;white-space:nowrap">&nbsp; Age &nbsp;</td>
 214    <td class='under'>{pt_age}&nbsp;</td>
 215    <td style="width:1%;white-space:nowrap">&nbsp; {label_gender} &nbsp;</td>
 216    <td class='under'>{pt_sex}&nbsp;</td>
 217   </tr>
 218  </table>
 219
 220  <table class='linetable'>
 221   <tr>
 222    <td style="width:1%;white-space:nowrap">{label_clinic} &nbsp;</td>
 223    <td class='under'>{to_organization}&nbsp;</td>
 224   </tr>
 225  </table>
 226
 227  <table class='linetable'>
 228   <tr>
 229    <td style="width:1%;white-space:nowrap">{label_address} &nbsp;</td>
 230    <td class='under'>{to_street}, {to_city} {to_state}&nbsp;</td>
 231    <td style="width:1%;white-space:nowrap">&nbsp; {label_postal} &nbsp;</td>
 232    <td class='under'>{to_zip}&nbsp;</td>
 233    <td style="width:1%;white-space:nowrap">&nbsp; {label_phone} &nbsp;</td>
 234    <td class='under'>{to_phone}&nbsp;</td>
 235   </tr>
 236  </table>
 237
 238  <table class='linetable'>
 239   <tr>
 240    <td style="width:1%;white-space:nowrap">{label_ref_reason} &nbsp;</td>
 241    <td class='under'>{ref_body}&nbsp;</td>
 242   </tr>
 243  </table>
 244
 245  <br />&nbsp;<br />{label_history_summary}:
 246
 247  <table class='linetable'>
 248   <tr>
 249    <td style="width:1%;white-space:nowrap">{label_bp} &nbsp;</td>
 250    <td class='under'>{v_bps}/{v_bpd}&nbsp;</td>
 251    <td style="width:1%;white-space:nowrap">&nbsp; {label_ht} &nbsp;</td>
 252    <td class='under'>{v_height}&nbsp;</td>
 253    <td style="width:1%;white-space:nowrap">&nbsp; {label_wt} &nbsp;</td>
 254    <td class='under'>{v_weight}&nbsp;</td>
 255   </tr>
 256  </table>
 257
 258  <p>
 259
 260  <table class='linetable'>
 261   <tr>
 262    <td style="width:1%;white-space:nowrap">{label_ref_name_sig} &nbsp;</td>
 263    <td class='under'>{ref_refer_from}&nbsp;</td>
 264   </tr>
 265  </table>
 266
 267  <table class='linetable'>
 268   <tr>
 269    <td style="width:1%;white-space:nowrap">{label_special_name_sig} &nbsp;</td>
 270    <td class='under'>{ref_refer_to}&nbsp;</td>
 271   </tr>
 272  </table>
 273
 274 </div></div>
 275 <br style="clear:both;" /><!-- kludge to fix bizarre Firefox problem with page breaks -->
 276 <p style='page-break-after: always'></p>
 277 <div class='borderdiv'><div class='paddingdiv'>
 278
 279  <table class="bigtable">
 280   <tr>
 281    <td class='mainhead'>
 282     {header2}
 283     <span class='subhead'>{label_subhead_referred}</span>
 284    </td>
 285    <td style="text-align:right;width:10%;white-space:nowrap">
 286     <table border='1' style="padding:2px;border-spacing:0;border-collapse:collapse">
 287      <tr>
 288       <td style="white-space:nowrap">{label_clinic_id}</td>
 289       <td style='width:60pt;white-space:nowrap'>{fac_facility_npi}</td>
 290      </tr>
 291      <tr>
 292       <td style="white-space:nowrap">{label_clinic_id}</td>
 293       <td style="white-space:nowrap">{ref_pid}</td>
 294      </tr>
 295      <tr>
 296       <td style="white-space:nowrap">{label_control_no}</td>
 297       <td style="white-space:nowrap">{ref_id}</td>
 298      </tr>
 299      <tr>
 300       <td style="white-space:nowrap">{label_date}</td>
 301       <td style="white-space:nowrap">{ref_reply_date}&nbsp;</td>
 302      </tr>
 303     </table>
 304    </td>
 305   </tr>
 306  </table>
 307
 308  <table class='linetable'>
 309   <tr>
 310    <td style="width:1%;white-space:nowrap">{label_name} &nbsp;</td>
 311    <td class='under'>{pt_title} {pt_fname} {pt_mname} {pt_lname}&nbsp;</td>
 312    <td style="width:1%;white-space:nowrap">&nbsp; {label_age} &nbsp;</td>
 313    <td class='under'>{pt_age}&nbsp;</td>
 314    <td style="width:1%;white-space:nowrap">&nbsp; {label_gender} &nbsp;</td>
 315    <td class='under'>{pt_sex}&nbsp;</td>
 316   </tr>
 317  </table>
 318
 319  <table class='linetable'>
 320   <tr>
 321    <td style="width:1%;white-space:nowrap">{label_clinic} &nbsp;</td>
 322    <td class='under'>{to_organization}&nbsp;</td>
 323   </tr>
 324  </table>
 325
 326  <table class='linetable'>
 327   <tr>
 328    <td style="width:1%;white-space:nowrap">{label_diagnosis} &nbsp;</td>
 329    <td class='under'>{ref_reply_init_diag}&nbsp;</td>
 330   </tr>
 331  </table>
 332
 333  <table class='linetable'>
 334   <tr>
 335    <td style="width:1%;white-space:nowrap">{label_findings} &nbsp;</td>
 336    <td class='under'>{ref_reply_findings}&nbsp;</td>
 337   </tr>
 338  </table>
 339
 340  <table class='linetable'>
 341   <tr>
 342    <td style="width:1%;white-space:nowrap">{label_final_diagnosis} &nbsp;</td>
 343    <td class='under'>{ref_reply_final_diag}&nbsp;</td>
 344   </tr>
 345  </table>
 346
 347  <table class='linetable'>
 348   <tr>
 349    <td style="width:1%;white-space:nowrap">{label_services_provided} &nbsp;</td>
 350    <td class='under'>{ref_reply_services}&nbsp;</td>
 351   </tr>
 352  </table>
 353
 354  <table class='linetable'>
 355   <tr>
 356    <td style="width:1%;white-space:nowrap">{label_recommendations} &nbsp;</td>
 357    <td class='under'>{ref_reply_recommend}&nbsp;</td>
 358   </tr>
 359  </table>
 360
 361  <table class='linetable'>
 362   <tr>
 363    <td style="width:1%;white-space:nowrap">{label_scripts_and_referrals} &nbsp;</td>
 364    <td class='under'>{ref_reply_rx_refer}&nbsp;</td>
 365   </tr>
 366  </table>
 367
 368  <table class='linetable'>
 369   <tr>
 370    <td style="width:1%;white-space:nowrap">{label_special_name_sig} &nbsp;</td>
 371    <td class='under'>{ref_refer_to}&nbsp;</td>
 372   </tr>
 373  </table>
 374
 375 </div></div>
 376
 377 <!-- This should really be in the onload handler but that seems to be unreliable and can crash Firefox 3. -->
 378 <script type="text/javascript">
 379  var win = top.printLogPrint ? top : opener.top;
 380  win.printLogPrint(window);
 381 </script>
 382
 383 </body>
 384 </html>