4 <meta http-equiv=
"content-type" content=
"text/html; charset=UTF-8">
5 <title>{label_webpage_title}
</title>
6 <style type=
"text/css">
8 font-family: sans-serif
;
11 background-color: #fff;
19 border-color: #000000;
27 border-collapse: collapse
;
29 .bigtable, .linetable {
36 border-collapse: collapse
;
49 border-width: 0 0 1px 0;
50 border-color: #999999;
72 background-color: #999999;
73 margin: 12pt 0 12pt 0;
89 <!-- The double div resolves a difference between Firefox and IE in treatment of padding. -->
90 <div class='borderdiv'
><div class='paddingdiv'
>
92 <table class=
"bigtable">
94 <td class='mainhead'
style=
"vertical-align:top">
96 <span class='subhead'
>{label_subhead_clinic}
</span>
98 <td style=
"text-align:right;width:10%;white-space:nowrap">
99 <table border='
1'
style=
"padding:2px;border-spacing:0;border-collapse:collapse">
101 <td style=
"white-space:nowrap">{label_clinic_id}
</td>
102 <td style='width:
60pt;white-space:nowrap'
>{fac_facility_npi}
</td>
105 <td style=
"white-space:nowrap">{label_clinic_id}
</td>
106 <td style=
"white-space:nowrap">{ref_pid}
</td>
109 <td style=
"white-space:nowrap">{label_control_no}
</td>
110 <td style=
"white-space:nowrap">{ref_id}
</td>
113 <td style=
"white-space:nowrap">{label_date}
</td>
114 <td style=
"white-space:nowrap">{ref_refer_date}
</td>
121 <table class='linetable'
>
123 <td style=
"width:1%;white-space:nowrap">{label_name}
</td>
124 <td class='under'
>{pt_title} {pt_fname} {pt_mname} {pt_lname}
</td>
125 <td style=
"width:1%;white-space:nowrap"> {label_age}
</td>
126 <td class='under'
>{pt_age}
</td>
127 <td style=
"width:1%;white-space:nowrap"> {label_gender}
</td>
128 <td class='under'
>{pt_sex}
</td>
132 <table class='linetable'
>
134 <td style=
"width:1%;white-space:nowrap">{label_address}
</td>
135 <td class='under'
>{pt_street}, {pt_city} {pt_state}
</td>
136 <td style=
"width:1%;white-space:nowrap"> {label_postal}
</td>
137 <td class='under'
>{pt_postal_code}
</td>
138 <td style=
"width:1%;white-space:nowrap"> {label_phone}
</td>
139 <td class='under'
>{pt_phone_home}
</td>
143 <table class='linetable'
>
145 <td style=
"width:1%;white-space:nowrap">{label_ref_reason}
</td>
146 <td class='under'
>{ref_body}
</td>
150 <table class='linetable'
>
152 <td style=
"width:1%;white-space:nowrap">{label_diagnosis}
</td>
153 <td class='under'
>{ref_refer_diag}
</td>
157 <table class='linetable'
>
159 <td style=
"width:1%;white-space:nowrap">{label_ref_class}
</td>
160 <td class='under'
>{ref_refer_risk_level}
</td>
164 <table class='linetable'
>
166 <td style=
"width:1%;white-space:nowrap">{label_dr_name_sig}
</td>
167 <td class='under'
>{ref_refer_from}
</td>
171 <table class='linetable'
>
173 <td style=
"width:1%;white-space:nowrap">{label_refer_to}
</td>
174 <td class='under'
>{ref_refer_to} / {to_organization}
</td>
180 <table class=
"bigtable">
182 <td class='mainhead'
>
184 <span class='subhead'
>{label_subhead_patient}
</span>
186 <td style=
"text-align:right;width:10%;white-space:nowrap">
187 <table border='
1'
style=
"padding:2px;border-spacing:0;border-collapse:collapse">
189 <td style=
"white-space:nowrap">{label_clinic_id}
</td>
190 <td style='width:
60pt;white-space:nowrap'
>{fac_facility_npi}
</td>
193 <td style=
"white-space:nowrap">{label_clinic_id}
</td>
194 <td style=
"white-space:nowrap">{ref_pid}
</td>
197 <td style=
"white-space:nowrap">{label_control_no}
</td>
198 <td style=
"white-space:nowrap">{ref_id}
</td>
201 <td style=
"white-space:nowrap">{label_date}
</td>
202 <td style=
"white-space:nowrap">{ref_refer_date}
</td>
209 <table class='linetable'
>
211 <td style=
"width:1%;white-space:nowrap">{label_name}
</td>
212 <td class='under'
>{pt_title} {pt_fname} {pt_mname} {pt_lname}
</td>
213 <td style=
"width:1%;white-space:nowrap"> Age
</td>
214 <td class='under'
>{pt_age}
</td>
215 <td style=
"width:1%;white-space:nowrap"> {label_gender}
</td>
216 <td class='under'
>{pt_sex}
</td>
220 <table class='linetable'
>
222 <td style=
"width:1%;white-space:nowrap">{label_clinic}
</td>
223 <td class='under'
>{to_organization}
</td>
227 <table class='linetable'
>
229 <td style=
"width:1%;white-space:nowrap">{label_address}
</td>
230 <td class='under'
>{to_street}, {to_city} {to_state}
</td>
231 <td style=
"width:1%;white-space:nowrap"> {label_postal}
</td>
232 <td class='under'
>{to_zip}
</td>
233 <td style=
"width:1%;white-space:nowrap"> {label_phone}
</td>
234 <td class='under'
>{to_phone}
</td>
238 <table class='linetable'
>
240 <td style=
"width:1%;white-space:nowrap">{label_ref_reason}
</td>
241 <td class='under'
>{ref_body}
</td>
245 <br /> <br />{label_history_summary}:
247 <table class='linetable'
>
249 <td style=
"width:1%;white-space:nowrap">{label_bp}
</td>
250 <td class='under'
>{v_bps}/{v_bpd}
</td>
251 <td style=
"width:1%;white-space:nowrap"> {label_ht}
</td>
252 <td class='under'
>{v_height}
</td>
253 <td style=
"width:1%;white-space:nowrap"> {label_wt}
</td>
254 <td class='under'
>{v_weight}
</td>
260 <table class='linetable'
>
262 <td style=
"width:1%;white-space:nowrap">{label_ref_name_sig}
</td>
263 <td class='under'
>{ref_refer_from}
</td>
267 <table class='linetable'
>
269 <td style=
"width:1%;white-space:nowrap">{label_special_name_sig}
</td>
270 <td class='under'
>{ref_refer_to}
</td>
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'
>
279 <table class=
"bigtable">
281 <td class='mainhead'
>
283 <span class='subhead'
>{label_subhead_referred}
</span>
285 <td style=
"text-align:right;width:10%;white-space:nowrap">
286 <table border='
1'
style=
"padding:2px;border-spacing:0;border-collapse:collapse">
288 <td style=
"white-space:nowrap">{label_clinic_id}
</td>
289 <td style='width:
60pt;white-space:nowrap'
>{fac_facility_npi}
</td>
292 <td style=
"white-space:nowrap">{label_clinic_id}
</td>
293 <td style=
"white-space:nowrap">{ref_pid}
</td>
296 <td style=
"white-space:nowrap">{label_control_no}
</td>
297 <td style=
"white-space:nowrap">{ref_id}
</td>
300 <td style=
"white-space:nowrap">{label_date}
</td>
301 <td style=
"white-space:nowrap">{ref_reply_date}
</td>
308 <table class='linetable'
>
310 <td style=
"width:1%;white-space:nowrap">{label_name}
</td>
311 <td class='under'
>{pt_title} {pt_fname} {pt_mname} {pt_lname}
</td>
312 <td style=
"width:1%;white-space:nowrap"> {label_age}
</td>
313 <td class='under'
>{pt_age}
</td>
314 <td style=
"width:1%;white-space:nowrap"> {label_gender}
</td>
315 <td class='under'
>{pt_sex}
</td>
319 <table class='linetable'
>
321 <td style=
"width:1%;white-space:nowrap">{label_clinic}
</td>
322 <td class='under'
>{to_organization}
</td>
326 <table class='linetable'
>
328 <td style=
"width:1%;white-space:nowrap">{label_diagnosis}
</td>
329 <td class='under'
>{ref_reply_init_diag}
</td>
333 <table class='linetable'
>
335 <td style=
"width:1%;white-space:nowrap">{label_findings}
</td>
336 <td class='under'
>{ref_reply_findings}
</td>
340 <table class='linetable'
>
342 <td style=
"width:1%;white-space:nowrap">{label_final_diagnosis}
</td>
343 <td class='under'
>{ref_reply_final_diag}
</td>
347 <table class='linetable'
>
349 <td style=
"width:1%;white-space:nowrap">{label_services_provided}
</td>
350 <td class='under'
>{ref_reply_services}
</td>
354 <table class='linetable'
>
356 <td style=
"width:1%;white-space:nowrap">{label_recommendations}
</td>
357 <td class='under'
>{ref_reply_recommend}
</td>
361 <table class='linetable'
>
363 <td style=
"width:1%;white-space:nowrap">{label_scripts_and_referrals}
</td>
364 <td class='under'
>{ref_reply_rx_refer}
</td>
368 <table class='linetable'
>
370 <td style=
"width:1%;white-space:nowrap">{label_special_name_sig}
</td>
371 <td class='under'
>{ref_refer_to}
</td>
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
);