<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>
        </tr>
    </table>

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

    <div style="position: relative;">
        <h1 style="
        text-align: center;
        font-weight: bold;
        font-size: 1rem;
        margin: 0;
      ">
            Lembar Formulir Rawat Jalan <br> Layanan Kedokteran Fisik dan Rehabilitasi
        </h1>
    </div>

    <div style="
        margin-top: 1.5rem;
        border: 1px solid black;
        padding: 0.3rem;
    ">
        <table style="margin-top: 0.3rem;margin-bottom: 0.3rem;">
            <tr>
                <td style="width: 19rem;"><b>I. Identitas Pasien</b></td>
                <td style="width: 4rem;">No. RM</td>
                <td class="data-colon">: </td>
                <td>{{ .Repalcable }}</td>
            </tr>
        </table>
        <table>
            <tr>
                <td style="width: 10rem; height: 1.5rem;">
                    Nama Pasien
                </td>
                <td class="data-colon">: </td>
                <td>{{ .Repalcable }}</td>
            </tr>
            <tr>
                <td style="height: 1.5rem;">
                    Tanggal Lahir
                </td>
                <td class="data-colon">: </td>
                <td>{{ .Repalcable }}</td></tr>
            <tr>
                <td style="height: 1.5rem;">
                    Aalamat
                </td>
                <td class="data-colon">: </td>
                <td>{{ .Repalcable }}</td></tr>
            <tr>
                <td style="height: 1.5rem;">
                    Telp / HP
                </td>
                <td class="data-colon">: </td>
                <td>{{ .Repalcable }}</td></tr>
            <tr>
                <td style="height: 1.5rem;">
                    Hubungan dengan Tertanggung
                </td>
                <td class="data-colon">: </td>
                <td>
                    &#9745; Suami / Istri
                    &emsp;&emsp;   
                    &#9634; Anak
                </td>
            </tr>
        </table>
    </div>

    
    <div style="
        margin-top: 1.5rem;
        border: 1px solid black;
        padding: 0.3rem;
    ">
        <table style="margin-top: 0.3rem;margin-bottom: 0.3rem;">
            <tr>
                <td style="width: 19rem;"><b>II. Diisi oleh Dokter SpKFR</b></td>
            </tr>
        </table>
        <table>
            <tr>
                <td style="width: 14rem; height: 1.5rem;">
                    Tanggal Pelayanan
                </td>
                <td class="data-colon">: </td>
                <td>{{ .Repalcable }}</td></tr>
            </tr>
            <tr>
                <td style="height: 1.5rem;">
                    Anamnesa
                </td>
                <td class="data-colon">: </td>
                <td>{{ .Repalcable }}</td></tr>
            </tr>
            <tr>
                <td style="height: 1.5rem;">
                    Pemeriksaan Fisik dan Uji Fungsi
                </td>
                <td class="data-colon">: </td>
                <td>{{ .Repalcable }}</td></tr>
            </tr>
            <tr>
                <td style="height: 1.5rem;">
                    Diagnosis Medis (ICD-10)
                </td>
                <td class="data-colon">: </td>
                <td>{{ .Repalcable }}</td></tr>
            </tr>
            <tr>
                <td style="height: 1.5rem;">
                    Diagnosis Fungsi (ICD-10)
                </td>
                <td class="data-colon">: </td>
                <td>{{ .Repalcable }}</td></tr>
            </tr>
            <tr>
                <td style="height: 1.5rem;">
                    Pemeriksaan Penunjang
                </td>
                <td class="data-colon">: </td>
                <td>{{ .Repalcable }}</td></tr>
            </tr>
            <tr>
                <td style="height: 1.5rem;">
                    Tata Laksana KFR (ICD 9 CM)
                </td>
                <td class="data-colon">: </td>
                <td>{{ .Repalcable }}</td></tr>
            </tr>
            <tr>
                <td style="height: 1.5rem;">
                    Anjuran
                </td>
                <td class="data-colon">: </td>
                <td>{{ .Repalcable }}</td></tr>
            </tr>
            <tr>
                <td style="height: 1.5rem;">
                    Evaluasi
                </td>
                <td class="data-colon">: </td>
                <td>{{ .Repalcable }}</td></tr>
            </tr>
            <tr>
                <td style="height: 1.5rem;">
                    Suspek Penyakit Akibat Kerja
                </td>
                <td class="data-colon">: </td>
                <td>
                    &#9745; Ya &emsp; ( {{ .Repalcable }} )

                    <br>
                    &#9634; Tidak
                </td>
            </tr>
        </table>
    </div>

    <table style="margin-top: 2rem;">
        <tr>
            <td style="text-align: center;">
                TTD Pasien
            </td>
            <td style="text-align: center;">
                Tempat & Tanggal<br>
                Cap dan TTD Dr. SpKFR
            </td>
        </tr>
        <tr><td style="height: 6rem;"></td></tr>
        <tr>
            <td style="height: 10rem;text-align: center;">
                (........................................................)
            </td>
            <td style="height: 10rem;text-align: center;">
                (........................................................)
            </td>
        </tr>
    </table>

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

</html>