<?php echo '<font size=1 color="#000099" face="verdana,arial">' . $batch_nr . '</font> <br>'; echo "<img src='" . $root_path . "classes/barcode/image.php?code={$batch_nr}&style=68&type=I25&width=145&height=40&xres=2&font=5' border=0>"; ?> </td> <td class=fva2_ml10><div class=fva2_ml10><font size=3 color="#0000ff"><b><?php echo $LDRequestOf . $formtitle; ?> </b></font> <br> <?php echo $LDWithMatchTest . " " . $LDByBloodBank; echo '<br>' . $LDYes . ' '; printRadioButton('match_sample', 1); echo ' ' . $LDNo . ' '; printRadioButton('match_sample', 0); ?> </td> </tr> <tr valign="top" bgcolor="<?php echo $bgc1; ?> " > <td valign="bottom" align="right"> <!-- Block for bloodgroup, Rh-factor, Kell --> <table border=0 cellspacing=0 cellpadding=2 bgcolor="#000000" width=100%> <tr> <td>
echo $bgc1; ?> " valign="top"> <td align="right" ><font size=1 color="#cc0000" face="verdana,arial"> <?php echo $LDImmuneSupp; ?> </td> <td colspan=2><?php printRadioButton('immune_supp', 1); ?> <?php echo $LDYes; ?> <?php printRadioButton('immune_supp', 0); ?> <?php echo $LDNo; ?> <br> </td> </tr> <tr bgcolor="#fff3f3" valign="top"> <td colspan=3><font size=2 color="#ee6666" face="verdana,arial"><b><?php echo $LDFillLabOnly; ?> </b></td> </tr>
<td align="right"><div class=fva2_ml10><?php echo $LDPregnantPossible; ?> <?php echo $LDYes; ?> </td> <td><font size=2 face="verdana,arial"> <?php printRadioButton('if_pregnant', 1); ?> <?php echo $LDNo; ?> <?php printRadioButton('if_pregnant', 0); ?> </td> </tr> </table> <br> </td> </tr> <tr bgcolor="<?php echo $bgc1; ?> "> <td colspan=2><div class=fva2_ml10><?php
?> " method="post"> <?php printInput("number", "patient_insee", "Numéro INSEE", true); ?> <?php printInput("text", "patient_firstName", "Prénom du patient", true); ?> <?php printInput("text", "patient_lastName", "Nom du patient", true); ?> <?php printInput("date", "patient_dateOfBirth", "Date de naissance", true); ?> <?php printRadioButton("patient_sex", "Sexe", array("F" => "Femme", "M" => "Homme", "O" => "Autre"), true); ?> <?php printInput("number", "patient_size", "Taille (cm)", true); ?> <?php printInput("number", "patient_weight", "Poids (kg)", true); ?> <?php printCountryDropDownList("patient_countryOfResidence", "Pays de résidence", true); ?> <?php printNextButton(); ?> </form> </div>