217 lines
7.0 KiB
HTML
217 lines
7.0 KiB
HTML
<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> |