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referral_template.html
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referral_template.html
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<!DOCTYPE html>
<html>
<head>
<meta http-equiv="content-type" content="text/html; charset=UTF-8">
<title>{label_webpage_title}</title>
<style type="text/css">
body, td {
font-family: sans-serif;
font-weight: normal;
font-size: 9pt;
background-color: #fff;
}
.borderdiv {
width: 524pt;
height: 668pt;
padding: 0;
border-style: solid;
border-width: 1px;
border-color: #000000;
}
.paddingdiv {
padding: 10pt;
}
.bigtable{
padding: 0px;
border-spacing: 0;
border-collapse: collapse;
}
.bigtable, .linetable {
width: 504pt;
}
.linetable {
margin: 11pt 0 0 0;
padding: 0px;
border-spacing: 0;
border-collapse: collapse;
}
.mainhead {
font-weight: bold;
font-size: 14pt;
text-align: left;
}
.subhead {
font-weight: bold;
font-size: 8pt;
}
.under {
border-style: solid;
border-width: 0 0 1px 0;
border-color: #999999;
}
.ftitletable {
width: 100%;
margin: 0 0 0 0;
}
.ftitlecell1 {
vertical-align: top;
text-align: left;
font-size: 14pt;
font-weight: bold;
}
.ftitlecell2 {
vertical-align: top;
text-align: right;
font-size: 9pt;
padding-right: 10pt;
}
hr {
border: 0;
height: 6pt;
color: #999999;
background-color: #999999;
margin: 12pt 0 12pt 0;
}
.tdLabelContainer {
text-align: right;
width: 10%;
vertical-align: top;
white-space: nowrap;
}
.mainhead {
vertical-align: top;
}
</style>
</head>
<body>
<!-- The double div resolves a difference between Firefox and IE in treatment of padding. -->
<div class='borderdiv'><div class='paddingdiv'>
<table class="bigtable">
<tr>
<td class='mainhead' style="vertical-align:top">
{header1}
<span class='subhead'>{label_subhead_clinic}</span>
</td>
<td style="text-align:right;width:10%;white-space:nowrap">
<table border='1' style="padding:2px;border-spacing:0;border-collapse:collapse">
<tr>
<td style="white-space:nowrap">{label_clinic_id}</td>
<td style='width:60pt;white-space:nowrap'>{fac_facility_npi}</td>
</tr>
<tr>
<td style="white-space:nowrap">{label_clinic_id}</td>
<td style="white-space:nowrap">{ref_pid}</td>
</tr>
<tr>
<td style="white-space:nowrap">{label_control_no}</td>
<td style="white-space:nowrap">{ref_id}</td>
</tr>
<tr>
<td style="white-space:nowrap">{label_date}</td>
<td style="white-space:nowrap">{ref_refer_date} </td>
</tr>
</table>
</td>
</tr>
</table>
<table class='linetable'>
<tr>
<td style="width:1%;white-space:nowrap">{label_name} </td>
<td class='under'>{pt_title} {pt_fname} {pt_mname} {pt_lname} </td>
<td style="width:1%;white-space:nowrap"> {label_age} </td>
<td class='under'>{pt_age} </td>
<td style="width:1%;white-space:nowrap"> {label_gender} </td>
<td class='under'>{pt_sex} </td>
</tr>
</table>
<table class='linetable'>
<tr>
<td style="width:1%;white-space:nowrap">{label_address} </td>
<td class='under'>{pt_street}, {pt_city} {pt_state} </td>
<td style="width:1%;white-space:nowrap"> {label_postal} </td>
<td class='under'>{pt_postal_code} </td>
<td style="width:1%;white-space:nowrap"> {label_phone} </td>
<td class='under'>{pt_phone_home} </td>
</tr>
</table>
<table class='linetable'>
<tr>
<td style="width:1%;white-space:nowrap">{label_ref_reason} </td>
<td class='under'>{ref_body} </td>
</tr>
</table>
<table class='linetable'>
<tr>
<td style="width:1%;white-space:nowrap">{label_diagnosis} </td>
<td class='under'>{ref_refer_diag} </td>
</tr>
</table>
<table class='linetable'>
<tr>
<td style="width:1%;white-space:nowrap">{label_ref_class} </td>
<td class='under'>{ref_refer_risk_level} </td>
</tr>
</table>
<table class='linetable'>
<tr>
<td style="width:1%;white-space:nowrap">{label_dr_name_sig} </td>
<td class='under'>{ref_refer_from} </td>
</tr>
</table>
<table class='linetable'>
<tr>
<td style="width:1%;white-space:nowrap">{label_refer_to} </td>
<td class='under'>{ref_refer_to} / {to_organization} </td>
</tr>
</table>
<hr />
<table class="bigtable">
<tr>
<td class='mainhead'>
{header1}
<span class='subhead'>{label_subhead_patient}</span>
</td>
<td style="text-align:right;width:10%;white-space:nowrap">
<table border='1' style="padding:2px;border-spacing:0;border-collapse:collapse">
<tr>
<td style="white-space:nowrap">{label_clinic_id}</td>
<td style='width:60pt;white-space:nowrap'>{fac_facility_npi}</td>
</tr>
<tr>
<td style="white-space:nowrap">{label_clinic_id}</td>
<td style="white-space:nowrap">{ref_pid}</td>
</tr>
<tr>
<td style="white-space:nowrap">{label_control_no}</td>
<td style="white-space:nowrap">{ref_id}</td>
</tr>
<tr>
<td style="white-space:nowrap">{label_date}</td>
<td style="white-space:nowrap">{ref_refer_date} </td>
</tr>
</table>
</td>
</tr>
</table>
<table class='linetable'>
<tr>
<td style="width:1%;white-space:nowrap">{label_name} </td>
<td class='under'>{pt_title} {pt_fname} {pt_mname} {pt_lname} </td>
<td style="width:1%;white-space:nowrap"> Age </td>
<td class='under'>{pt_age} </td>
<td style="width:1%;white-space:nowrap"> {label_gender} </td>
<td class='under'>{pt_sex} </td>
</tr>
</table>
<table class='linetable'>
<tr>
<td style="width:1%;white-space:nowrap">{label_clinic} </td>
<td class='under'>{to_organization} </td>
</tr>
</table>
<table class='linetable'>
<tr>
<td style="width:1%;white-space:nowrap">{label_address} </td>
<td class='under'>{to_street}, {to_city} {to_state} </td>
<td style="width:1%;white-space:nowrap"> {label_postal} </td>
<td class='under'>{to_zip} </td>
<td style="width:1%;white-space:nowrap"> {label_phone} </td>
<td class='under'>{to_phone} </td>
</tr>
</table>
<table class='linetable'>
<tr>
<td style="width:1%;white-space:nowrap">{label_ref_reason} </td>
<td class='under'>{ref_body} </td>
</tr>
</table>
<br /> <br />{label_history_summary}:
<table class='linetable'>
<tr>
<td style="width:1%;white-space:nowrap">{label_bp} </td>
<td class='under'>{v_bps}/{v_bpd} </td>
<td style="width:1%;white-space:nowrap"> {label_ht} </td>
<td class='under'>{v_height} </td>
<td style="width:1%;white-space:nowrap"> {label_wt} </td>
<td class='under'>{v_weight} </td>
</tr>
</table>
<p>
<table class='linetable'>
<tr>
<td style="width:1%;white-space:nowrap">{label_ref_name_sig} </td>
<td class='under'>{ref_refer_from} </td>
</tr>
</table>
<table class='linetable'>
<tr>
<td style="width:1%;white-space:nowrap">{label_special_name_sig} </td>
<td class='under'>{ref_refer_to} </td>
</tr>
</table>
</div></div>
<br style="clear:both;" /><!-- kludge to fix bizarre Firefox problem with page breaks -->
<p style='page-break-after: always'></p>
<div class='borderdiv'><div class='paddingdiv'>
<table class="bigtable">
<tr>
<td class='mainhead'>
{header2}
<span class='subhead'>{label_subhead_referred}</span>
</td>
<td style="text-align:right;width:10%;white-space:nowrap">
<table border='1' style="padding:2px;border-spacing:0;border-collapse:collapse">
<tr>
<td style="white-space:nowrap">{label_clinic_id}</td>
<td style='width:60pt;white-space:nowrap'>{fac_facility_npi}</td>
</tr>
<tr>
<td style="white-space:nowrap">{label_clinic_id}</td>
<td style="white-space:nowrap">{ref_pid}</td>
</tr>
<tr>
<td style="white-space:nowrap">{label_control_no}</td>
<td style="white-space:nowrap">{ref_id}</td>
</tr>
<tr>
<td style="white-space:nowrap">{label_date}</td>
<td style="white-space:nowrap">{ref_reply_date} </td>
</tr>
</table>
</td>
</tr>
</table>
<table class='linetable'>
<tr>
<td style="width:1%;white-space:nowrap">{label_name} </td>
<td class='under'>{pt_title} {pt_fname} {pt_mname} {pt_lname} </td>
<td style="width:1%;white-space:nowrap"> {label_age} </td>
<td class='under'>{pt_age} </td>
<td style="width:1%;white-space:nowrap"> {label_gender} </td>
<td class='under'>{pt_sex} </td>
</tr>
</table>
<table class='linetable'>
<tr>
<td style="width:1%;white-space:nowrap">{label_clinic} </td>
<td class='under'>{to_organization} </td>
</tr>
</table>
<table class='linetable'>
<tr>
<td style="width:1%;white-space:nowrap">{label_diagnosis} </td>
<td class='under'>{ref_reply_init_diag} </td>
</tr>
</table>
<table class='linetable'>
<tr>
<td style="width:1%;white-space:nowrap">{label_findings} </td>
<td class='under'>{ref_reply_findings} </td>
</tr>
</table>
<table class='linetable'>
<tr>
<td style="width:1%;white-space:nowrap">{label_final_diagnosis} </td>
<td class='under'>{ref_reply_final_diag} </td>
</tr>
</table>
<table class='linetable'>
<tr>
<td style="width:1%;white-space:nowrap">{label_services_provided} </td>
<td class='under'>{ref_reply_services} </td>
</tr>
</table>
<table class='linetable'>
<tr>
<td style="width:1%;white-space:nowrap">{label_recommendations} </td>
<td class='under'>{ref_reply_recommend} </td>
</tr>
</table>
<table class='linetable'>
<tr>
<td style="width:1%;white-space:nowrap">{label_scripts_and_referrals} </td>
<td class='under'>{ref_reply_rx_refer} </td>
</tr>
</table>
<table class='linetable'>
<tr>
<td style="width:1%;white-space:nowrap">{label_special_name_sig} </td>
<td class='under'>{ref_refer_to} </td>
</tr>
</table>
</div></div>
<!-- This should really be in the onload handler but that seems to be unreliable and can crash Firefox 3. -->
<script type="text/javascript">
var win = top.printLogPrint ? top : opener.top;
win.printLogPrint(window);
</script>
</body>
</html>