<html>

<head>
    <meta charset="UTF-8" />
    <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="margin-top: 1rem;">
        <tr>
            <td style="width: 9rem;">
                Tanggal Terbit
            </td>
            <td class="data-colon">: </td>
            <td>{{ .Repalcable }}</td>
        </tr>
        <tr>
            <td>
                No. RM
            </td>
            <td class="data-colon">: </td>
            <td>{{ .Repalcable }}</td>
        </tr>
        <tr>
            <td>
                Nama
            </td>
            <td class="data-colon">: </td>
            <td>{{ .Repalcable }}</td>
        </tr>
        <tr>
            <td>
                Tanggal Lahir
            </td>
            <td class="data-colon">: </td>
            <td>{{ .Repalcable }}</td>
        </tr>
    </table>

    <hr style="margin: 20px 0" />
    <h1 style="
        text-align: center;
        font-weight: bold;
        font-size: 1rem;
        margin: 0;
      ">
        FORM A
    </h1>

    <section>
        <h4 class="section-title">Kajian Awal Medis:</i></h4>
        <table style="margin-top: 0.3rem;">
            <tr>
                <td>
                    &#9745; Kasus Dengan Penyakit Kronis, Katastropik (memerlukan Pembiayaan Tinggi), Terminal
                </td>
            </tr>
            <tr>
                <td>
                    &#9634; Status Fungsional Rendah, Kebutuhan Bantuan ADL(Activity Daily Living) Yang Tinggi
                </td>
            </tr>
        </table>
    </section>

    <section>
        <h4 class="section-title">ASSESMEN:</h4>
        <table style="margin-top: 0.3rem;">
            
        </table>
    </section>

    <section>
        <h4 class="section-title">IDENTIFIKASI MASALAH:</h4>
        <table style="margin-top: 0.3rem;">
            
        </table>
    </section>

    <section>
        <h4 class="section-title">PERENCANAAN:</h4>
        <table style="margin-top: 0.3rem;">
            
        </table>
    </section>

    <table style="margin-top: 3rem;">
        <tr>
            <td></td>
            <td style="text-align: center;width: 15rem;">
                2025-10-08 16:06:22
            </td>
        </tr>
        <tr>
            <td></td>
            <td style="text-align: center;height: 10rem;width: 15rem;">
                GATOT SUBROTO,AMd.Kep
            </td>
        </tr>
    </table>

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

</html>