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Form #2 PA : source https://jsbin.com/videco
Raw
index.html
<!DOCTYPE html>
<html>
<head>
<meta charset="utf-8">
<meta name="viewport" content="width=device-width">
<title>JS Bin</title>
<style>
body {
font-size: 16px;
font-family:Candara,Calibri,Segoe,Segoe UI,Optima,Arial,sans-serif;
}
.spasi5 { height:5px; }
.spasi10 { height:10px; }
.spasi15 { height:15px; }
td.tengah {
text-align: center;
}
td.tebel {
font-weight: bold;
}
.biru {
background: #0072c6;
}
.double-bar {
border-top: 4px double #999;
padding: 10px 0;
color: #000;
}
td.kanan {
text-align: right;
}
p.solid { border-style: solid; color:#000 }
p.kepala { border-style: solid; color:#0072c6; padding-left: 7px}
</style>
</head>
<body>
<!-- HEADER -->
<table width="100%" border="0">
<tr>
<td><img src="https://surat.rsuppersahabatan.co.id/logo-text.png"</td>
<td>
<table>
<tr>
<td>Nomor PA</td>
<td>:</td>
<td>NOMOR_PA</td>
</tr>
</table>
</td>
</tr>
<tr>
<td>Laboratorium Patologi Anatomik</td>
<td rowspan="4">
<table width ="100%" border="1">
<tr>
<td>Nama</td>
<td>: Mr. XXX</td>
</tr>
<tr>
<td>RM</td>
<td>: 9898989</td>
</tr>
<tr>
<td>Tanggal Lahir/ Umur</td>
<td>: 12/12/1212 - 100thn</td>
</tr>
<tr>
<td colspan="3">(Mohon diisi atau templekan sticker)</td>
</tr>
</table>
</td>
</tr>
<tr>
<td>Jalan Persahabatan Raya No. 1 Rawamangun,</td>
</tr>
<tr>
<td>Jakarta Timur, 13230,</td>
</tr>
<tr>
<td>Telp. 999888 888777 666</td>
</tr>
</table>
<div class="spasi15"></div>
<table width="100%" border="0" class="kepala">
<thead>
<tr>
<td>
<p class="kepala">
Diterima Tanggal:
<br />
Jam:
</p>
</td>
</tr>
</thead>
</table>
<table width="100%" border="0">
<thead>
<tr><td class="tengah tebel biru" colspan="3">PEMERIKSAAN PATOLOGI MOLEKULER</td></tr>
</thead>
<tr>
<td>DATA DOKTER/ RS PENGIRIM</td>
<td>DATA PASIEN</td>
<tr>
<tr>
<td>
<table width ="100%" border="0">
<tr>
<td>Nama Dokter</td>
<td>:</td>
<td>...........................</td>
</tr>
<tr>
<td>RS Asal</td>
<td>:</td>
<td>...........................</td>
</tr>
<tr>
<td>Telpon Dokter</td>
<td>:</td>
<td>...........................</td>
</tr>
<tr>
<td>Bagian/ Unit</td>
<td>:</td>
<td>...........................</td>
</tr>
</table>
</td>
<td>
<table width ="100%" border="0">
<tr>
<td>Alamat Lengkap</td>
<td>:</td>
<td>...........................</td>
</tr>
<tr>
<td>Bangsa/ Suku</td>
<td>:</td>
<td>...........................</td>
</tr>
<tr>
<td>No. Telp</td>
<td>:</td>
<td>...........................</td>
</tr>
</table>
</td>
</tr>
</table>
<div class="spasi10"></div>
<div class="double-bar"></div>
<table width="100%" border="0">
<tr>
<td class="tebel" width="20%">Riwayat/ Diagnosa Klinik</td>
<td width="2%">:</td>
<td>...................</td>
</tr>
<tr>
<td>Diagnosa PA</td>
<td>:</td>
<td>....................</td>
</tr>
<tr>
<td colspan="3" height="50"></td>
</tr>
<tr>
<td colspan="3">Permintaan Pemeriksaan:</td>
</tr>
<tr>
<td colspan="3"><input type="radio">EEGFR Mutation (exon 18,19,29,21) <br /> <input type="radio">Lainnya: ......................</td>
</tr>
<tr>
<td colspan="3" height="50"></td>
</tr>
<tr>
<td colspan="3">Jenis Bahan yang diterima:</td>
</tr>
<tr>
<td colspan="3">
<table width="70%" border="1">
<thead>
<tr>
<td>Jenis Sediaan</td>
<td>Nomor</td>
<td>Jumlah</td>
</tr>
</thead>
<tbody>
<tr>
<td><input type="radio" />Blok Parafin</td>
<td></td>
<td></td>
</tr>
<tr>
<td><input type="radio" />Slide Histopatologi (HE)</td>
<td></td>
<td></td>
</tr>
<tr>
<td><input type="radio" />Slide Sitologi</td>
<td></td>
<td></td>
</tr>
<tr>
<td><input type="radio" />Unstained Slide (min. 45 slide @5nm)</td>
<td></td>
<td></td>
</tr>
<tr>
<td><input type="radio" />LBC</td>
<td></td>
<td></td>
</tr>
<tr>
<td><input type="radio" />Lainnya</td>
<td></td>
<td></td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td colspan="3" height="100"></td>
</tr>
<tr>
<td rowspan="3"></td>
<td class="kanan" colspan="2">Jakarta, Tgl: .../ ..../ .....</td>
</tr>
<tr>
<td colspan="2" height="100"></td>
</tr>
<tr>
<td class="kanan" colspan="2">Tanda Tangan dan Nama Jelas Dokter Pengirim</td>
</tr>
<tr>
<td colspan="3">
<p class="solid">
Catatan:<br />
- Untuk Pemeriksaan molekuler yang baik dibutuhkan slide yang mengandung Kurang/ Lebih 200 sel tumor, dengan persentase sel tumor lebih besar dari 50%. <br />
- Waktu Pemeriksaan adalah tanggal bahan diterima di loket Unit Patologi Anatomi RSUP Persahabatan sampai hasil selesai.
</p>
</td>
</tr>
</table>
<script id="jsbin-source-html" type="text/html">
<!DOCTYPE html>
<html>
<head>
<meta charset="utf-8">
<meta name="viewport" content="width=device-width">
<title>JS Bin</title>
<style>
body {
font-size: 16px;
font-family:Candara,Calibri,Segoe,Segoe UI,Optima,Arial,sans-serif;
}
.spasi5 { height:5px; }
.spasi10 { height:10px; }
.spasi15 { height:15px; }
td.tengah {
text-align: center;
}
td.tebel {
font-weight: bold;
}
.biru {
background: #0072c6;
}
.double-bar {
border-top: 4px double #999;
padding: 10px 0;
color: #000;
}
td.kanan {
text-align: right;
}
p.solid { border-style: solid; color:#000 }
p.kepala { border-style: solid; color:#0072c6; padding-left: 7px}
</style>
</head>
<body>
<\!-- HEADER -->
<table width="100%" border="0">
<tr>
<td><img src="https://surat.rsuppersahabatan.co.id/logo-text.png"</td>
<td>
<table>
<tr>
<td>Nomor PA</td>
<td>:</td>
<td>NOMOR_PA</td>
</tr>
</table>
</td>
</tr>
<tr>
<td>Laboratorium Patologi Anatomik</td>
<td rowspan="4">
<table width ="100%" border="1">
<tr>
<td>Nama</td>
<td>: Mr. XXX</td>
</tr>
<tr>
<td>RM</td>
<td>: 9898989</td>
</tr>
<tr>
<td>Tanggal Lahir/ Umur</td>
<td>: 12/12/1212 - 100thn</td>
</tr>
<tr>
<td colspan="3">(Mohon diisi atau templekan sticker)</td>
</tr>
</table>
</td>
</tr>
<tr>
<td>Jalan Persahabatan Raya No. 1 Rawamangun,</td>
</tr>
<tr>
<td>Jakarta Timur, 13230,</td>
</tr>
<tr>
<td>Telp. 999888 888777 666</td>
</tr>
</table>
<div class="spasi15"></div>
<table width="100%" border="0" class="kepala">
<thead>
<tr>
<td>
<p class="kepala">
Diterima Tanggal:
<br />
Jam:
</p>
</td>
</tr>
</thead>
</table>
<table width="100%" border="0">
<thead>
<tr><td class="tengah tebel biru" colspan="3">PEMERIKSAAN PATOLOGI MOLEKULER</td></tr>
</thead>
<tr>
<td>DATA DOKTER/ RS PENGIRIM</td>
<td>DATA PASIEN</td>
<tr>
<tr>
<td>
<table width ="100%" border="0">
<tr>
<td>Nama Dokter</td>
<td>:</td>
<td>...........................</td>
</tr>
<tr>
<td>RS Asal</td>
<td>:</td>
<td>...........................</td>
</tr>
<tr>
<td>Telpon Dokter</td>
<td>:</td>
<td>...........................</td>
</tr>
<tr>
<td>Bagian/ Unit</td>
<td>:</td>
<td>...........................</td>
</tr>
</table>
</td>
<td>
<table width ="100%" border="0">
<tr>
<td>Alamat Lengkap</td>
<td>:</td>
<td>...........................</td>
</tr>
<tr>
<td>Bangsa/ Suku</td>
<td>:</td>
<td>...........................</td>
</tr>
<tr>
<td>No. Telp</td>
<td>:</td>
<td>...........................</td>
</tr>
</table>
</td>
</tr>
</table>
<div class="spasi10"></div>
<div class="double-bar"></div>
<table width="100%" border="0">
<tr>
<td class="tebel" width="20%">Riwayat/ Diagnosa Klinik</td>
<td width="2%">:</td>
<td>...................</td>
</tr>
<tr>
<td>Diagnosa PA</td>
<td>:</td>
<td>....................</td>
</tr>
<tr>
<td colspan="3" height="50"></td>
</tr>
<tr>
<td colspan="3">Permintaan Pemeriksaan:</td>
</tr>
<tr>
<td colspan="3"><input type="radio">EEGFR Mutation (exon 18,19,29,21) <br /> <input type="radio">Lainnya: ......................</td>
</tr>
<tr>
<td colspan="3" height="50"></td>
</tr>
<tr>
<td colspan="3">Jenis Bahan yang diterima:</td>
</tr>
<tr>
<td colspan="3">
<table width="70%" border="1">
<thead>
<tr>
<td>Jenis Sediaan</td>
<td>Nomor</td>
<td>Jumlah</td>
</tr>
</thead>
<tbody>
<tr>
<td><input type="radio" />Blok Parafin</td>
<td></td>
<td></td>
</tr>
<tr>
<td><input type="radio" />Slide Histopatologi (HE)</td>
<td></td>
<td></td>
</tr>
<tr>
<td><input type="radio" />Slide Sitologi</td>
<td></td>
<td></td>
</tr>
<tr>
<td><input type="radio" />Unstained Slide (min. 45 slide @5nm)</td>
<td></td>
<td></td>
</tr>
<tr>
<td><input type="radio" />LBC</td>
<td></td>
<td></td>
</tr>
<tr>
<td><input type="radio" />Lainnya</td>
<td></td>
<td></td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td colspan="3" height="100"></td>
</tr>
<tr>
<td rowspan="3"></td>
<td class="kanan" colspan="2">Jakarta, Tgl: .../ ..../ .....</td>
</tr>
<tr>
<td colspan="2" height="100"></td>
</tr>
<tr>
<td class="kanan" colspan="2">Tanda Tangan dan Nama Jelas Dokter Pengirim</td>
</tr>
<tr>
<td colspan="3">
<p class="solid">
Catatan:<br />
- Untuk Pemeriksaan molekuler yang baik dibutuhkan slide yang mengandung Kurang/ Lebih 200 sel tumor, dengan persentase sel tumor lebih besar dari 50%. <br />
- Waktu Pemeriksaan adalah tanggal bahan diterima di loket Unit Patologi Anatomi RSUP Persahabatan sampai hasil selesai.
</p>
</td>
</tr>
</table>
</body>
</html></script>
</body>
</html>
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