<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" />
    
    
<table class="border-table" style="margin-top: 1rem;">        
        <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;">
                Diagnosa
            </td>
            <td>{{ .Repalcable }}</td>
        </tr>
        <tr>
            <td style="width: 7rem;min-height: 6rem;">
                Permintaan Terapi
            </td>
            <td>{{ .Repalcable }}</td>
        </tr>
    </table>


    <table class="border-table" style="margin-top: 1rem;">
        <tr>
            <th rowspan="2" style="width: 17rem;">
                PELAKSANAAN PROGRAM
            </th>
            <th rowspan="2">
                Tanggal
            </th>
            <th colspan="3">
                TTD
            </th>
        </tr>
        <tr>
            <th>
                PASIEN
            </th>
            <th>
                DOKTER
            </th>
            <th>
                TERAPIS
            </th>
        </tr>
        <tr>
            <td style="height: 2rem;padding-left: 0.5rem;">1. {{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td><td></td><td></td><td></td>
        </tr>
        <tr>
            <td style="height: 2rem;padding-left: 0.5rem;">2. {{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td><td></td><td></td><td></td>
        </tr>
        <tr>
            <td style="height: 2rem;padding-left: 0.5rem;">3. {{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td><td></td><td></td><td></td>
        </tr>
        <tr>
            <td style="height: 2rem;padding-left: 0.5rem;">4. {{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td><td></td><td></td><td></td>
        </tr>
        <tr>
            <td style="height: 2rem;padding-left: 0.5rem;">5. {{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td><td></td><td></td><td></td>
        </tr>
        <tr>
            <td style="height: 2rem;padding-left: 0.5rem;">6. {{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td><td></td><td></td><td></td>
        </tr>
        <tr>
            <td style="height: 2rem;padding-left: 0.5rem;">7. {{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td><td></td><td></td><td></td>
        </tr>
        <tr>
            <td style="height: 2rem;padding-left: 0.5rem;">8. {{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td><td></td><td></td><td></td>
        </tr>
        <tr>
            <td style="height: 2rem;padding-left: 0.5rem;">9. {{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td><td></td><td></td><td></td>
        </tr>
        <tr>
            <td style="height: 2rem;padding-left: 0.5rem;">10. {{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td><td></td><td></td><td></td>
        </tr>
        <tr>
            <td style="height: 2rem;padding-left: 0.5rem;">11. {{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td><td></td><td></td><td></td>
        </tr>
        <tr>
            <td style="height: 2rem;padding-left: 0.5rem;">12. {{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td><td></td><td></td><td></td>
        </tr>
        <tr>
            <td style="height: 2rem;padding-left: 0.5rem;">13. {{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td><td></td><td></td><td></td>
        </tr>
        <tr>
            <td style="height: 2rem;padding-left: 0.5rem;">14. {{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td><td></td><td></td><td></td>
        </tr>
        <tr>
            <td style="height: 2rem;padding-left: 0.5rem;">15. {{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td><td></td><td></td><td></td>
        </tr>
        <tr>
            <td style="height: 2rem;padding-left: 0.5rem;">16. {{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td><td></td><td></td><td></td>
        </tr>
        <tr>
            <td style="height: 2rem;padding-left: 0.5rem;">17. {{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td><td></td><td></td><td></td>
        </tr>
        <tr>
            <td style="height: 2rem;padding-left: 0.5rem;">18. {{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td><td></td><td></td><td></td>
        </tr>
        <tr>
            <td style="height: 2rem;padding-left: 0.5rem;">19. {{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td><td></td><td></td><td></td>
        </tr>
        <tr>
            <td style="height: 2rem;padding-left: 0.5rem;">20. {{ .Repalcable }}</td>
            <td>{{ .Repalcable }}</td><td></td><td></td><td></td>
        </tr>
    </table>

    

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

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

</html>