<!DOCTYPE html>
<html lang="en">
	<head>
		<title> Cetak Data Pasien</title>
		<style type="text/css">
		   .left    { text-align: left;}
		   .right   { text-align: right;}
		   .center  { text-align: center;}
		   .justify { text-align: justify;}
		</style>
		<style type="text/css">
			.table1 {
				font-family: sans-serif;
				color: #444;
				border-collapse: collapse;
				width: 100%;
				border: 1px solid #f2f5f7;
				font-size: 0.90em;
			}

			.table1 tr th{
				background: #35A9DB;
				color: #fff;
				font-weight: normal;
			}

			.table1, th, td {
				padding: 8px 20px;
				text-align: left;
			}

			.table1 tr:hover {
				background-color: #f5f5f5;
			}

			.table1 tr:nth-child(even) {
				background-color: #f2f2f2;
			}
		</style>
	</head>
	
<body style="padding: 10px 20px">
	<img src="images/logo-rs.png" width="300" height="">
	<h4>FORMULIR PENDAFTARAN PASIEN</h4>
	<h5>A. IDENTITAS PASIEN</h5>
	<table align="" cellpadding="5" width="100%" class="table1">
		<tr><td width="">Nama Lengkap</td><td>: <?php echo $nama;?></td><td>No RM</td><td>:</td></tr>
		<tr><td>Tempat & Tgl Lahir</td><td>: <?php echo $tmp_lhr.", ".$tgl_lhr;?></td><td></td><td></td></tr>
		<tr><td>Jenis Kelamin</td><td>: <?php if($jkel=='L') echo "Laki-laki"; else echo "Perempuan";?></td><td>Agama</td><td class=""><span>: <?php //echo $jkel;?></span></tr>
		
		<tr><td>Alamat</td><td>: <?php echo $alamat;?></td><td></td><td></td></tr>
		<tr><td width="10%">Kelurahan</td><td width="50%">: <?php //echo $jkel;?></td><td width="10%">Kecamatan</td><td width="30%">: <?php echo $kecamatan;?></td></tr>
		
		<tr><td>Kabupaten/Kota</td><td>: <?php echo $kota;?></td><td>Propinsi</td><td>: <?php echo $propinsi;?></td></tr>
		
		<!--tr><td>Pendidikan Terakhir</td><td colspan="3">: <?php //echo $jkel;?></td></tr>
		<tr><td>Pekerjaan/Bagian</td><td colspan="3">: <?php //echo $jkel;?></td></tr>
		<tr><td>Alamat Kantor</td><td colspan="3">: <?php //echo $jkel;?></td></tr-->
		<tr><td>Kewarganegaraan</td><td>: </td><td>Suku Bangsa</td><td>: </td></tr>
		
	</table>
	
	<h5 align="left">B. IDENTITAS PENANGGUNG JAWAB</h5>
	<table align="" cellpadding="5" class="table1">
		<tr><td width="15%">Nama Lengkap</td><td>: <?php echo $pj;?></td><td width="25%">Hubungan Dengan Pasien</td><td>: <?php echo $hub_pj;?></td></tr>		
		<!--tr><td width="">Hubungan Dengan Pasien</td><td colspan="3">: <?php echo $hub_pj;?></td></tr-->		
		<tr><td>Telp/HP</td><td colspan="3">: <?php //echo $propinsi;?></td></tr>		
		<!--tr><td>Alamat</td><td colspan="3">: <?php //echo $propinsi;?></td></tr>		
		<tr><td width="10%">Kecamatan</td><td width="50%">: <?php// echo $propinsi;?></td><td width="10%">Kabupaten/Kota</td><td width="30%">: <?php //echo $propinsi;?></td></tr>
		<tr><td>Propinsi</td><td colspan="3">: <?php //echo $propinsi;?></td></tr>
		<tr><td>Pekerjaan/Bagian</td><td colspan="3">: <?php //echo $propinsi;?></td></tr>
		<tr><td>Alamat Kantor</td><td colspan="3">: <?php //echo $propinsi;?></td></tr-->		
		
	</table>
	<h5 align="left">C. PENJAMIN BIAYA RUMAH SAKIT</h5>
	<table align="" cellpadding="5" class="table1">
		<tr><td width="11%">Jaminan Kesehatan</td><td>: <?php echo $penjamin;?></td></tr>
		<?php if($idpenjamin=='2'){ 
			$asuran=$perusahaan;
			$perush="-";
			$noasuran=$no_asuransi;
		}else if($idpenjamin=='3'){ 
			$asuran="-";
			$perush=$perusahaan;
			$noasuran=$no_asuransi;
		}else{
			$asuran="-";
			$perush="-";
			$noasuran="-";
		}
			?>
		<tr><td>Asuransi</td><td>: <?php echo $asuran;?></td></tr>
		<?php //}else if($idpenjamin=='3'){ ?>
		<tr><td>Perusahaan</td><td>: <?php echo $perush;?></td></tr>
		<?php //} ?>
		<tr><td>No Asuransi</td><td>: <?php echo $noasuran;?></td></tr>
		
	</table>
	<!--table align="center" border="1">
		<tr><td>Tangerang Selatan, </td><td></td></tr>
		<tr><td>Penanggung Jawab Pasien</td><td>Petugas Pendaftaran</td></tr>
		<tr><td>(cbcbcbcbc)</td><td>( mnm,nmn )</td></tr>
	</table-->
	<div style="padding-top:20px;font-family: sans-serif;font-weight: normal;">
		<div style="float:left; margin-left:100px;">Tangerang Selatan, </div><br>
		<div style="float:left; margin-left:100px;">Penanggung Jawab Pasien</div> <div style="float:right; margin-right:100px;">Petugas Pendaftaran</div><br>
	</div>
	<div style="padding-top:40px;font-family: sans-serif;font-weight: normal;">
		<div style="float:left; margin-left:100px;">( <?php echo $pj;?> )</div> <div style="float:right; margin-right:100px;">(...............................)</div><br>
	</div>
</body>

</html>