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