<html>

<head>
    <meta charset="UTF-8" />
    <title>General Consent</title>
    <style>
        body {
            padding: 2rem 3rem;
        }
        table {
            width: 100%;
            border-collapse: collapse
        }
        td {
            vertical-align: top;
        }
        .border-table, .border-table td, .border-table th {
            border: 1px solid black;
        }
        .section-title {            
            margin-top: 1rem;
            margin-bottom: 0rem;
        }
        .data-label {            
            width: 9rem;
        }
        .data-colon {            
            width: 0.1234rem;
        }
    </style>
</head>

<body style="font-family: Arial, sans-serif; line-height: 1.4">
    <table style="width: 100%; border-collapse: collapse">
        <tr>
            <td style="text-align: center">
                <img src="logo-1.png" alt="logo" style="height: 70px" />
            </td>
            <td style="text-align: center">
                <div style="font-size: 14px; font-weight: bold">
                    PEMERINTAH PROVINSI JAWA TIMUR
                </div>
                <div style="font-size: 14px; font-weight: bold">
                    RUMAH SAKIT UMUM DAERAH Dr. SAIFUL ANWAR
                </div>
                <div style="font-size: 13px">
                    TERAKREDITASI KARS VERSI 2012 TINGKAT PARIPURNA
                </div>
                <div style="margin-top: 8px">
                    Jl. Jaksa Agung Suprapto No. 2 MALANG 65111
                </div>
                <div>Telp. (0341) 362101, Fax. (0341) 362110</div>
                <div>Email: rsu-drsaifulanwar@jatimprov.go.id</div>
                <div>Website: www.rsudsaifulanwar.jatimprov.go.id</div>
            </td>
            <td style="text-align: center">
                <img src="logo-rssa.png" alt="logo" style="height: 70px" />
            </td>
        </tr>
    </table>

    <hr style="margin: 20px 0" />

    <div style="position: relative;">
        <h1 style="
        text-align: center;
        font-weight: bold;
        font-size: 1rem;
        margin: 0;
      ">
        Protokol Terapi
    </h1>
    <p style="
        margin: 0;
        text-align: center;
      ">Layanan Kedokteran Fisik dan Rehabilitasi
    </p>
    <div style="padding-inline: 0.5rem;text-align: center;border: 1px solid black;position: absolute;right: 0;top: 0;">
Terapi Ke <br><br>
{{ .Repalcable }}
    </div>
    </div>
    
    
<table class="border-table" style="margin-top: 2rem;">        
        <tr>
            <td style="width: 7rem;">
                No RM
            </td>
            <td>{{ .Repalcable }}</td>
        </tr>
        <tr>
            <td style="width: 7rem;">
                Nama Pasien
            </td>
            <td>{{ .Repalcable }}</td>
        </tr>
        <tr>
            <td style="width: 7rem;">
                Tanggal Lahir
            </td>
            <td>{{ .Repalcable }}</td>
        </tr>
        <tr>
            <td style="width: 7rem;">
                Diagnosa
            </td>
            <td>{{ .Repalcable }}</td>
        </tr>
        <tr>
            <td style="width: 7rem;">
                Permintaan Terapi
            </td>
            <td>{{ .Repalcable }}</td>
        </tr>
        <tr>
            <td style="width: 7rem;">
               Frekuensi Terapi
            </td>
            <td style="padding-left: 0.5rem;">
                2 x Per Minggu &emsp; &emsp; &emsp;
                Evaluasi: 1 Bulan
            </td>
        </tr>
        <tr>
            <td style="width: 7rem;">
                Target Terapi
            </td>
            <td>{{ .Repalcable }}</td>
        </tr>
        <tr>
            <td style="width: 7rem;">
                Waktu Mencapai Target
            </td>
            <td>{{ .Repalcable }}</td>
        </tr>
    </table>


    <table class="border-table" style="margin-top: 1rem;">
        <tr>
            <th style="width: 2rem;">
                NO
            </th>
            <th>
                Tanggal
            </th>
            <th>
                Dokter
            </th>
            <th>
                Fisioterapi
            </th>
            <th>
                Terapi Wicara
            </th>
            <th>
                Okupansi Terapi
            </th>
            <th>
                Ortotik Prostetik
            </th>
            <th>
                PSM
            </th>
            <th>
                TTD Pasien
            </th>
        </tr>
        <tr>
            <td style="height: 3rem;text-align: center;">
                1
            </td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
        </tr>
        <tr>
            <td style="height: 3rem;text-align: center;">
                2
            </td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
        </tr>
        <tr>
            <td style="height: 3rem;text-align: center;">
                3
            </td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
        </tr>
        <tr>
            <td style="height: 3rem;text-align: center;">
                4
            </td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
        </tr>
        <tr>
            <td style="height: 3rem;text-align: center;">
                5
            </td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
        </tr>
        <tr>
            <td style="height: 3rem;text-align: center;">
                6
            </td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
        </tr>
        <tr>
            <td style="height: 3rem;text-align: center;">
                7
            </td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
        </tr>
        <tr>
            <td style="height: 3rem;text-align: center;">
                8
            </td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td>
        </tr>
    </table>

    
<table class="border-table" style="margin-top: 1rem;">
        <tr>
            <td style="height: 2rem;width: 7rem;">
                Evaluasi
            </td>
            <td>{{ .Repalcable }}</td>
        </tr>
        <tr>
            <td style="width: 7rem;">
                Rencana Selanjutnya
            </td>
            <td>{{ .Repalcable }}</td>
        </tr>
    </table>

    <table style="margin-top: 2rem;">
        <tr>
            <td></td>
            <td style="width: 15rem;">
                Malang,<br>
                Cap dan TTD Dr. SpKFR
            </td>
        </tr>
        <tr><td style="height: 6rem;"></td></tr>
        <tr>
            <td></td>
            <td style="height: 10rem;width: 15rem;">
                (........................................................)
            </td>
        </tr>
    </table>

    <div style="height: 3rem;"></div>
</body>

</html>