freemedforms-emr-resources 0.9.4-1 / usr / share / freemedforms / forms / subforms / generic / fullidentity / html / xx / mask.html

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<html>
<body>
<style type="text/css">
.__ident__formContent {
  font-size: 12pt;
  color: black;
  border: 2px solid gray;
}

.__ident__formContent .formHeader {
}

.__ident__formContent .formLabel {
  font-weight: 600;
  text-transform: uppercase;
  background-color: gray;/* #6d8526; #7f9a2c #6d8526 #A7C942*/
  color: white;
  padding: 2px;
  text-align: center;
}

.__ident__formContent .episodeHeader {
  margin: 0 2em 0 0;
  padding: 0px;
}

.__ident__formContent .episodeContent {
  margin-left: 3em;
}

.__ident__formContent .episodeLabel {
  font-weight: 600;
  font-size: 14pt;
  padding: 5px;
}

.__ident__formContent .episodeUserCreator {
  font-size: 9pt;
  color: gray;
  margin-left: 1em;
}

.__ident__formContent .episodeUserDate {
  font-size: 9pt;
  color: gray;
  margin-left: 1em;
}

</style>

<div class="__ident__formContent">

<div class="formHeader">
<div class="formLabel">[[EpisodeFormLabel]]</div>
</div> <!-- formHeader -->

<div class="episodeHeader">
<!--
    [<div class="episodeLabel">[EpisodeUserLabel] </div> ]
-->
  [<span class="episodeUserCreator">[EpisodeUserName.createdBy]</span>]
  [&nbsp;<span class="episodeUserDate">[EpisodeUserDate]</span>]
</div> <!-- episodeHeader -->

<div class="episodeContent">

<style type="text/css">
.__ident__formContent .identityContainer {
  font-size: 12pt;
  color: black;
}

.__ident__formContent .identityContainer #identName {
  font-weight: 600;
  font-size: 14pt;
}

.__ident__formContent .identityContainer #identDob {
}

.__ident__formContent .identityContainer #identAge {
}

.__ident__formContent .identityContainer #identAddress {
}

.__ident__formContent .identityContainer #contactTels {
}

.__ident__formContent .identityContainer #contactMobile {
}

.__ident__formContent .identityContainer #contactFaxes {
}

.__ident__formContent .identityContainer #contactMails {
}

.__ident__formContent .contactContainer {
  margin-top: 1em;
  /* border: solid 1px black; */
}

</style>

<div class="identityContainer">
    <span id="identName">{{~Patient.Identity.FullName~}}</span><br />
    <span id="identDob">Date of birth: {{~Patient.Age.DateOfBirth~}}</span><br />
    {{<span id="identAge">Date of death: ~Patient.Age.DateOfDeath~</span><br />}}
    <span id="identAddress">{{~Patient.Address.FullAddress~}}</span><br />
    {{<span id="identSocialNumber">Social number: ~Patient.Insurance.SocialNumber~{{, ~Patient.Insurance.SocialNumber2~}}{{, ~Patient.Insurance.SocialNumber3~}}{{, ~Patient.Insurance.SocialNumber4~}}{{Owned by: ~Patient.Insurance.SocialNumberOwnerName~{{, ~Patient.Insurance.SocialNumberOwnerAddress~}}}}</span>}}
</div> <!-- identityContainer -->

<div class="contactContainer">
    {{<span id="contactTels">Tels: ~Patient.Contact.Tels~</span><br />}}
    {{<span id="contactMobile">Mobile: ~Patient.Contact.MobilePhone~</span><br />}}
    {{<span id="contactFaxes">Faxes: ~Patient.Contact.Fax~</span><br />}}
    {{<span id="contactMails">Mails: ~Patient.Contact.Email~</span><br />}}
</div> <!-- contactContainer -->

<div class="profContainer">
    {{<span id="profession">{{~Form.Label.Subs::Tools::Identity::ProfGroup::Profession~}}: ~Form.Data.Item.Subs::Tools::Identity::ProfGroup::Profession~</span><br />}}
    {{<span id="professionSite">{{~Form.Label.Subs::Tools::Identity::ProfGroup::ProfessionSite~}}: ~Form.Data.Item.Subs::Tools::Identity::ProfGroup::ProfessionSite~</span><br />}}
    {{<span id="professionTels">{{~Form.Label.Subs::Tools::Identity::ProfGroup::ProfessionTels~}}: ~Form.Data.Item.Subs::Tools::Identity::ProfGroup::ProfessionTels~</span><br />}}
</div> <!-- profContainer -->

</div> <!-- episodeContent -->

</div> <!-- __ident__formContent -->

</body>
</html>

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