echo "</tr>"; echo "<tr>"; echo "<td><b>Name:</b></td>"; echo "<td><input type='text' class='linez' value='" . $ro->getPatientRecord_lastName() . ", " . $ro->getPatientRecord_firstName() . " " . $ro->getPatientRecord_middleName() . "'></td>"; echo "<td><b>Age/Sex:</b></td>"; echo "<td><input type='text' class='linez' value='" . $ro->getPatientRecord_age() . "/" . $ro->getPatientRecord_gender() . "'></td>"; echo "</tr>"; echo "<tr>"; echo "<Td><b>Date of Birth:</td>"; echo "<td></b><input type='text' class='linez' value='" . $ro->getPatientRecord_birthDate() . "'></tD>"; echo "<td><b>Status:</td>"; echo "<td></b><input type='text' class='linez' value='" . $ro->getPatientRecord_civilStatus() . "'></tD>"; echo "</tr>"; echo "<tr>"; echo "<Td><b>Physician:</b></td>"; echo "<td><input type='text' class='linez' value='" . $ro->getAttendingDoc($registrationNo, "ATTENDING") . "'></tD>"; echo "<Td><b>Room:</b></td>"; echo "<td> <input type='text' class='linez' value='" . $ro->getRegistrationDetails_room() . "'></tD>"; echo "</tr>"; echo "</table>"; echo "</center>"; echo "<Br>"; echo "<center>"; echo $ro->ENCRYPT_DECRYPT($ro->doubleSelectNow_notDeleted("labSavedResult", "result", "itemNo", $itemNo, "registrationNo", $registrationNo)); echo "</center>"; if ($ro->selectNow("labSavedResult", "morphology", "itemNo", $itemNo) != "") { echo "<b>Morphology: </b>" . $ro->selectNow("labSavedResult", "morphology", "itemNo", $itemNo); } else { } echo "<Br>"; if ($ro->selectNow("labSavedResult", "remarks", "itemNo", $itemNo) != "") {
echo "<td><font size=2>THIS HOSPITAL FROM <input type=text class='underLine2' value='" . $ro->getRegistrationDetails_dateRegistered() . "'></font>\n<font size=2>TO</font>\n<input type=text class='underLine2' value='" . $ro->getRegistrationDetails_dateUnregistered() . "' >\n</td>"; echo "</tr>"; echo "<tr>"; echo "<td><font size=2>WITH THE FOLLOWING FINDINGS AND OR DIAGNOSIS:</font><input type='text' name='d1' class='underline2'></td>"; echo "</tr>"; echo "</table>"; echo "<input type=text name='d2' class='underLine3'>"; echo "<br>"; echo "<input type=text name='d3' class='underLine3'>"; echo "<br><Br>"; echo "<table border=0>"; echo "<tr>"; echo "<td><font size=2>THE CERTIFICATION IS ISSUED UPON REQUEST OF</font> <input type=text class='underLine'> </td>"; echo "</tr>"; echo "<tr>"; echo "<td><font size=2>FOR</font> <input type=text class='underLine3'> </td>"; echo "</tr>"; echo "</table>"; echo "<br><br>"; echo "<table border=0>"; echo "<tr>"; echo "<td width='25%'> </td>"; echo "<td width='10%'><input type='text' class='underLine4' value='" . $ro->getAttendingDoc($registrationNo, "Attending") . "'><br> <font size=2>ATTENDING PHYSICIAN</font></td>"; echo "</tr>"; echo "</table>"; $ro->coconutHidden("registrationNo", $registrationNo); $ro->coconutButton("Printable Version"); $ro->coconutFormStop(); ?> </div>
$ro = new database1(); $ro->getPatientProfile($registrationNo); echo "<center><b><font size=5>" . $ro->getReportInformation("hmoSOA_name") . "</font></b></center>"; echo "<center><font size=3>" . $ro->getReportInformation("hmoSOA_address") . "</font></center>"; echo "<center><font size=2>Tel No. (062) 2143237</font></center>"; echo "<br>"; echo "<center>CONSENT FOR ADMISSION</center>"; echo "<br><br><br>"; echo "<Table border=0 width='100%'>"; echo "<tr>"; echo "<td width='70%'></td>"; echo "<td width='85%'>Date: " . date("M d, Y") . "</td>"; echo "</tr>"; echo "</table>"; echo "<br>"; echo " I , _________________________________________________ hereby voluntarily and willingly authorized <br> Dr. <b><u>__" . $ro->getAttendingDoc($registrationNo, "ATTENDING") . "__</u></b> to treat and to admit __<b><u>" . $ro->getPatientRecord_lastName() . ", " . $ro->getPatientRecord_firstName() . "</u></b>__ <br> at PAGADIAN CITY MEDICAL CENTER."; echo "<br><br>"; echo "<Table border=0 width='100%'>"; echo "<tr>"; echo "<td width='70%'></td>"; echo "<td width='85%'>_________________________________________<br><font size=2>Signature Over Printed Name</font></td>"; echo "</tr>"; echo "<tr>"; echo "<td width='70%'></td>"; echo "<td width='85%'></td>"; echo "</tr>"; echo "<tr>"; echo "<td width='70%'></td>"; echo "<td width='85%'></td>"; echo "</tr>"; echo "<tr>";