MediRecords includes generic Pathology and Radiology request templates that are non-branded, making them suitable for use with any company. While these standard templates are functional, many practices prefer to add their own logo, signature, or branding elements to create a more personalised and professional look.
This article guides you through the process of customising these templates using HTML, adding your logo, and assigning the template to the desired companies.
Contents
- Copying the HTML Code
- Creating Your Template in MediRecords
- Pasting the HTML Code
- Adding Your Logo
- Pathology Request Template
- Radiology Request Template
Copying the HTML Code
- Scroll to the bottom of this article and locate the HTML code box.
- Choose the appropriate code for either Pathology or Radiology.
- Highlight all the text in the box.
- Right-click and choose Copy, or press Ctrl/Cmd + C on your keyboard.
Creating Your Template in MediRecords
- Go to More > Resources > Letter Templates.
- Click New Template.
- In the Save window, enter the following:
- Category: Letter
- Type: Investigations
- Sharing: Practice
- Name: Enter a name for your template
-
Description: Add a short description
- Click Save.
Pasting the HTML Code
- Click the View HTML button (symbol:
< / >).
- In the HTML editor, right-click and choose Paste, or press Ctrl/Cmd + V.
- Click Update.
-
Result:
✅ Tip: Do not edit any text within curly brackets{}. These are mail merge fields that automatically populate patient and test details.
Adding Your Logo
- Place your cursor where you want the logo to appear.
- Click the Insert Image button.
- Choose an existing image or click Upload to add a new one.
-
Click Insert to place the image in the template.
✅ Tip: Use a table to position your logo neatly. You can add a column to an existing table or create a new 1x1 table using the Create Table button.You can use alignment options (left or right) or adjust positioning with the Enter or Backspace keys to fine-tune the layout.
ℹ️ Note: Preview your template to ensure it looks professional. And once satisfied, assign the template to the desired companies.
Pathology Request Template:
HTML Code to be copied (per step 1)
<div class="paper-size-a4-portrait mr-letter-content"></div><span style="font-size:xx-small;"><div class="k-table-wrapper" contenteditable="true" style="border:1pt solid rgb(0, 0, 0);border-radius:0pt;background-color:rgba(0, 0, 0, 0);"><table style="padding:0mm;"><tbody><tr><td class="ui-resizable" style="width:46.03175%;height:43.7124px;padding:2mm 0mm 0mm 2mm;border-right-width:1pt;border-right-style:solid;border-right-color:#000000;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><strong>PATHOLOGY REQUEST</strong>
<br />
<br />
<br />
<br />
</div></td>
<td class="ui-resizable" style="width:27.84993%;padding:0mm;height:43.7124px;border-right-width:1pt;border-right-style:solid;border-right-color:#000000;border-left-width:1pt;border-left-style:solid;border-left-color:#000000;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;">MEDICARE CARD NUMBER
<br />
<br />
{patient-settings.medicare-number}
<br />
</div></div></td>
<td class="ui-resizable" style="height:43.7124px;padding:0mm;border-left-width:1pt;border-left-style:solid;border-left-color:#000000;background-color:rgba(0, 0, 0, 0);"> </td>
</tr>
</tbody></table>
</div><div class="k-table-wrapper" contenteditable="true" style="border-radius:0px 0px 0pt 0pt;border-left-width:1pt;border-left-style:solid;border-left-color:#000000;border-right-width:1pt;border-right-style:solid;border-right-color:#000000;border-bottom-width:1pt;border-bottom-style:solid;border-bottom-color:#000000;background-color:rgba(0, 0, 0, 0);"><table style="padding:1mm 0mm;height:88px;"><tbody><tr style="height:48px;"><td class="ui-resizable" style="width:57.86436%;padding:1mm 0mm;height:23.1189px;border-right-width:1pt;border-right-style:solid;border-right-color:#000000;border-bottom-width:1pt;border-bottom-style:solid;border-bottom-color:#000000;"><div contenteditable="true"><div class="k-table-wrapper" contenteditable="true" style="border-radius:0px;background-color:rgba(0, 0, 0, 0);"><table style="padding:0mm;"><tbody><tr><td class="ui-resizable" style="width:44.1103%;padding:1mm;height:16px;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">PATIENT SURNAME
<br />
<br />
{patient.last-name}
</div></td>
<td class="ui-resizable" style="width:48.1203%;padding:1mm;height:16px;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">GIVEN NAMES
<br />
<br />
{patient.first-name} {patient.middle-name}
<br />
</div></td>
<td class="ui-resizable" style="padding:1mm;height:16px;border-left-width:1pt;border-left-style:solid;border-left-color:#000000;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;">SEX
<br />
<br />
{patient.gender-code}
<br />
</div></div></td>
</tr>
</tbody></table>
</div></div></td>
<td class="ui-resizable" style="width:20.92352%;padding:1mm;height:23.1189px;border-right-width:1pt;border-right-style:solid;border-right-color:#000000;border-left-width:1pt;border-left-style:solid;border-left-color:#000000;border-bottom-width:1pt;border-bottom-style:solid;border-bottom-color:#000000;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">DATE OF BIRTH
<br />
<br />
{patient.DOB}
<br />
</div></td>
<td class="ui-resizable" style="padding:1mm;height:23.1189px;border-left-width:1pt;border-left-style:solid;border-left-color:#000000;border-bottom-width:1pt;border-bottom-style:solid;border-bottom-color:#000000;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">YOUR REF:
<br />
<br />
<br />
</div></td>
</tr>
<tr style="height:40px;"><td class="ui-resizable" style="width:57.86436%;padding:1mm;height:14.2882px;border-right-width:1pt;border-right-style:solid;border-right-color:#000000;border-top-width:1pt;border-top-style:solid;border-top-color:#000000;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">PATIENT ADDRESS
<br />
<br />
{patient.full-address}
<br />
</div></td>
<td class="ui-resizable" style="width:20.92352%;padding:1mm;height:14.2882px;border-right-width:1pt;border-right-style:solid;border-right-color:#000000;border-left-width:1pt;border-left-style:solid;border-left-color:#000000;border-top-width:1pt;border-top-style:solid;border-top-color:#000000;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">TEL
<br />
M: {patient.mobile-phone}
<br />
H: {patient.home-phone}
<br />
</div></td>
<td class="ui-resizable" style="padding:1mm;height:14.2882px;border-left-width:1pt;border-left-style:solid;border-left-color:#000000;border-top-width:1pt;border-top-style:solid;border-top-color:#000000;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">TEL (BUS)
<br />
<br />
{patient.office-phone}
<br />
</div></td>
</tr>
</tbody></table>
</div><div class="k-table-wrapper" contenteditable="true" style="border-radius:0px;border-left-width:1pt;border-left-style:solid;border-left-color:#000000;border-right-width:1pt;border-right-style:solid;border-right-color:#000000;border-bottom-width:1pt;border-bottom-style:solid;border-bottom-color:#000000;background-color:rgba(0, 0, 0, 0);"><table style="padding:0mm;"><tbody><tr><td class="ui-resizable" style="width:82.10678%;height:292.508px;padding:0mm;border-right-width:1pt;border-right-style:solid;border-right-color:#000000;border-bottom-width:1pt;border-bottom-style:solid;border-bottom-color:#000000;"><div contenteditable="true"><div class="k-table-wrapper" contenteditable="true" style="border-radius:0px;background-color:rgba(0, 0, 0, 0);"><table style="padding:0mm;"><tbody><tr><td class="ui-resizable" style="height:109.22px;padding:1mm;border-bottom-width:1pt;border-bottom-style:solid;border-bottom-color:#000000;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">TESTS REQUESTED
<br />
<div class="k-table-wrapper" contenteditable="true"><table><tbody><tr><td class="ui-resizable" style="height:96.6px;padding:1mm 0mm 0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><span style="font-size:xx-small;background-color:#ffffff;">{investigation-request.pathology-requests}</span>
</div></td>
</tr>
</tbody></table>
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="height:108.136px;padding:1mm;border-top-width:1pt;border-top-style:solid;border-top-color:#000000;border-bottom-width:1pt;border-bottom-style:solid;border-bottom-color:#000000;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">CLINICAL NOTES
<br />
<div class="k-table-wrapper" contenteditable="true"><table><tbody><tr><td class="ui-resizable" style="height:90px;padding:1mm 0mm 0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">{investigation-request.pathology-clinical-findings}
<br />
Site: {investigation-request.site-desc} {investigation-request.pregnancy-desc} {investigation-request.other-details-desc}
<br />
{investigation-request.fasting-desc}
<br />
</div></td>
</tr>
</tbody></table>
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="height:53.661px;padding:0mm;border-top-width:1pt;border-top-style:solid;border-top-color:#000000;"><div contenteditable="true"><div class="k-table-wrapper" contenteditable="true" style="border-radius:0px;background-color:rgba(0, 0, 0, 0);"><table style="padding:0mm;"><tbody><tr><td class="ui-resizable" style="width:60.177%;padding:0mm;border-right:1pt solid rgb(0, 0, 0);"><div contenteditable="true"><div class="k-table-wrapper" contenteditable="true" style="border-radius:0px;background-color:rgba(0, 0, 0, 0);"><table style="padding:1mm 1mm 0mm;"><tbody><tr><td class="ui-resizable" style="padding:1mm 1mm 0mm 0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div class="k-table-wrapper" contenteditable="true"><table style="display:table;"><tbody><tr><td class="ui-resizable" style="width:13.253%;padding:0mm 1mm 0mm 0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><strong>URGENT</strong>
</div></td>
<td class="ui-resizable" style="width:3.91566%;padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" data-value-checked="X" name="urgent" type="checkbox" value="{investigation-request.urgent-checked}" /></span>
</div></td>
<td class="ui-resizable" style="width:21.9879%;padding:0mm 1mm 0mm 0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:right;"><strong>PHONE</strong>
</div></div></td>
<td class="ui-resizable" style="width:4.21687%;padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" data-value-checked="X" name="urgent-phone" type="checkbox" value="{investigation-request.urgent-phone-checked}" /></span>
</div></td>
<td class="ui-resizable" style="width:17.4699%;padding:0mm 1mm 0mm 0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:right;"><strong>FAX</strong>
</div></div></td>
<td class="ui-resizable" style="width:4.21687%;padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" data-value-checked="X" name="urgent-fax" type="checkbox" value="{investigation-request.urgent-fax-checked}" /></span>
</div></td>
<td class="ui-resizable" style="padding:0mm 0mm 0mm 3mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">BY TIME:
<span style="font-size:xx-small;background-color:#ffffff;">{investigation-request.urgent-by-date}</span>
</div></td>
</tr>
</tbody></table>
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="padding:1mm 1mm 0mm 0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">PHONE/FAX No: {investigation-request.urgent-phone} / {investigation-request.urgent-fax}
</div></td>
</tr>
<tr><td class="ui-resizable" style="padding:1mm 1mm 0mm 0mm;height:15.373px;"><div contenteditable="true"><div class="k-table-wrapper" contenteditable="true"><table><tbody><tr><td class="ui-resizable" style="width:13.253%;padding:0mm 1mm 0mm 0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">PRIVATE
</div></td>
<td class="ui-resizable" style="width:3.91566%;padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" data-value-checked="X" name="billing-private" type="checkbox" value="{investigation-request.billing-private-checked}" /></span>
<br />
</div></div></td>
<td class="ui-resizable" style="width:21.9879%;padding:0mm 1mm 0mm 0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:right;">CONCESSION
</div></div></td>
<td class="ui-resizable" style="width:4.21687%;padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" data-value-checked="X" name="billing-concession" type="checkbox" value="{investigation-request.billing-concessional-checked}" /></span>
<br />
</div></div></td>
<td class="ui-resizable" style="width:17.4699%;padding:0mm 1mm 0mm 0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:right;">BULK BILL
</div></div></td>
<td class="ui-resizable" style="width:4.21687%;padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" data-value-checked="X" name="billing-direct-bill" type="checkbox" value="{investigation-request.billing-direct-bill-checked}" /></span>
<br />
</div></div></td>
<td class="ui-resizable" style="padding:0mm 0mm 0mm 3mm;background-color:rgba(0, 0, 0, 0);"> </td>
</tr>
</tbody></table>
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="padding:1mm 1mm 0mm 0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">VET AFFAIRS No: {patient-settings.dva-no}
</div></td>
</tr>
</tbody></table>
</div></div></td>
<td class="ui-resizable" style="padding:0mm;border-left-width:1pt;border-left-style:solid;border-left-color:#000000;"><div contenteditable="true"><div class="k-table-wrapper" contenteditable="true"><table><tbody><tr><td class="ui-resizable" style="width:63.964%;padding:0mm 1mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><strong>DOCTOR SIGNATURE</strong>
<br />
<br />
<br />
<br />
<br />
<br />
</div></td>
<td class="ui-resizable" style="padding:0mm 1mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><strong>REQUEST DATE</strong>
<br />
<br />
{general.todays-date}
<br />
<br />
<br />
<br />
</div></td>
</tr>
</tbody></table>
</div></div></td>
</tr>
</tbody></table>
</div></div></td>
</tr>
</tbody></table>
</div></div></td>
<td class="ui-resizable" style="height:292.508px;padding:1mm;border-left-width:1pt;border-left-style:solid;border-left-color:#000000;border-bottom-width:1pt;border-bottom-style:solid;border-bottom-color:#000000;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div class="k-table-wrapper" contenteditable="true" style="border-radius:0px;background-color:rgba(0, 0, 0, 0);"><table style="padding:1mm 1mm 0mm;"><tbody><tr><td class="ui-resizable" style="width:79.8246%;padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">Fasting
</div></td>
<td class="ui-resizable" style="padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" data-value-checked="X" name="fasting" type="checkbox" value="{investigation-request.fasting-checked}" /></span>
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="width:79.8246%;padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">Non-Fasting
</div></td>
<td class="ui-resizable" style="padding:0mm;"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" data-value-checked="X" name="non-fasting" type="checkbox" value="{investigation-request.non-fasting-checked}" /></span>
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="width:79.8246%;padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">Pregnant
</div></td>
<td class="ui-resizable" style="padding:0mm;"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" data-value-checked="X" name="pregnancy" type="checkbox" value="{investigation-request.pregnancy-checked}" /></span>
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="width:79.8246%;padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">Hormone Therapy
</div></td>
<td class="ui-resizable" style="padding:0mm;"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" data-value-checked="X" name="hormon-therapy" type="checkbox" value="{investigation-request.papsmear-other-hrt-checked}" /></span>
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="width:79.8246%;padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">LNMP
</div></td>
<td class="ui-resizable" style="padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" data-value-checked="X" name="pregnancy-lmp" type="checkbox" value="{investigation-request.pregnancy-lmp}" /></span>
<br />
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="width:79.8246%;padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">EDC
</div></td>
<td class="ui-resizable" style="padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" data-value-checked="X" name="pregnancy-edc" type="checkbox" value="{investigation-request.pregnancy-edc}" /></span>
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="width:79.8246%;padding:2mm 0mm 0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><span style="text-decoration:underline;">Cervical Cytology</span>
</div></td>
<td class="ui-resizable" style="padding:2mm 1mm 0mm;"> </td>
</tr>
<tr><td class="ui-resizable" style="width:79.8246%;padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><span style="text-decoration:underline;">Site</span> Cervix
<br />
</div></td>
<td class="ui-resizable" style="padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" data-value-checked="X" name="cervix" type="checkbox" value="{investigation-request.cervix-checked}" /></span>
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="width:79.8246%;padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"> Vaginal Vault
</div></td>
<td class="ui-resizable" style="padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" data-value-checked="X" name="vaginal-vault" type="checkbox" value="{investigation-request.vagina-vault-checked}" /></span>
<br />
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="width:79.8246%;padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"> Endometrium
</div></td>
<td class="ui-resizable" style="padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" data-value-checked="X" name="endometrium" type="checkbox" value="{investigation-request.endometrium-checked}" /></span>
<br />
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="width:79.8246%;padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"> Other
</div></td>
<td class="ui-resizable" style="padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" data-value-checked="X" name="cervical-other" type="checkbox" value="{investigation-request.other-checked}" /></span>
<br />
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="width:79.8246%;padding:0mm 1mm 0mm 0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">Post Natal
</div></td>
<td class="ui-resizable" style="padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" data-value-checked="X" name="post-natal" type="checkbox" value="{investigation-request.papsmear-other-post-natal-checked}" /></span>
<br />
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="width:79.8246%;padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">Post Menopausal
</div></td>
<td class="ui-resizable" style="padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" data-value-checked="X" name="post-menopausal" type="checkbox" value="{investigation-request.papsmear-other-post-menopausal-checked}" /></span>
<br />
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="width:79.8246%;padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">Radio Therapy
</div></td>
<td class="ui-resizable" style="padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" data-value-checked="X" name="radio-therapy" type="checkbox" value="{investigation-request.papsmear-other-radiotheraphy-checked}" /></span>
<br />
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="width:79.8246%;padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">IUCD
</div></td>
<td class="ui-resizable" style="padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" data-value-checked="X" name="iucd" type="checkbox" value="{investigation-request.papsmear-other-iucd-checked}" /></span>
<br />
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="width:79.8246%;padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">Abnormal Bleeding
</div></td>
<td class="ui-resizable" style="padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" data-value-checked="X" name="abnormal-bleeding" type="checkbox" value="{investigation-request.papsmear-other-abnormal-bleeding-checked}" /></span>
<br />
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="width:79.8246%;padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">Cervix Benign
</div></td>
<td class="ui-resizable" style="padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" data-value-checked="X" name="cervix-benign" type="checkbox" value="{investigation-request.papsmear-appearance-benign-checked}" /></span>
<br />
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="width:79.8246%;padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">Cervix Suspicious
</div></td>
<td class="ui-resizable" style="padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" data-value-checked="X" name="cervix-suspicious" type="checkbox" value="{investigation-request.papsmear-appearance-suspicious-checked}" /></span>
<br />
</div></div></td>
</tr>
</tbody></table>
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="width:82.10678%;padding:0px 0px 0px 1mm;border-right-width:1pt;border-right-style:solid;border-right-color:#000000;border-top-width:1pt;border-top-style:solid;border-top-color:#000000;height:24.8px;"><div contenteditable="true"><div class="k-table-wrapper" contenteditable="true" style="border-radius:0px;background-color:rgba(0, 0, 0, 0);"><table style="padding:1mm;"><tbody><tr><td class="ui-resizable" style="width:59.3972%;padding:1mm 1mm 1mm 0mm;border-right:1pt solid rgb(0, 0, 0);height:18.8882px;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">COPY REPORTS TO
<br />
<div class="k-table-wrapper" contenteditable="true"><table><tbody><tr><td class="ui-resizable" style="height:53px;"><div contenteditable="true">{investigation-request.copies-to}
</div></td>
</tr>
</tbody></table>
</div>HOSPITAL/WARD
</div></td>
<td class="ui-resizable" style="padding:1mm;border-left-width:1pt;border-left-style:solid;border-left-color:#000000;height:18.8882px;"><div contenteditable="true">REQUESTING DOCTOR
<br />
<div class="k-table-wrapper" contenteditable="true"><table><tbody><tr><td class="ui-resizable" style="height:64.1525px;"><div contenteditable="true">{current-user.full-name}
<br />
{practice.name}
<br />
{practice.address}
<br />
Ph: {practice.office-phone} Fax: {practice.fax}
<br />
{current-user.provider-no}
<br />
</div></td>
</tr>
</tbody></table>
</div></div></td>
</tr>
</tbody></table>
</div></div></td>
<td class="ui-resizable" style="padding:0mm 0mm 0mm 1mm;border-left-width:1pt;border-left-style:solid;border-left-color:#000000;border-top-width:1pt;border-top-style:solid;border-top-color:#000000;height:24.8px;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">COLLECTION CENTRE USE
<br />
<br />
<br />
<br />
<br />
<br />
<br />
</div></td>
</tr>
</tbody></table>
</div><span style="font-family:Arial, Helvetica, sans-serif;font-size:5pt;"><div class="k-table-wrapper" contenteditable="true" style="padding:1mm 0mm;"><table><tbody><tr><td class="ui-resizable" style="width:34.48773%;height:129.333px;"><div contenteditable="true"><div class="k-table-wrapper" contenteditable="true" style="border-top-width:1pt;border-top-style:solid;border-top-color:#000000;border-left-width:1pt;border-left-style:solid;border-left-color:#000000;border-bottom-width:1pt;border-bottom-style:solid;border-bottom-color:#000000;border-right-width:1pt;border-right-style:solid;border-right-color:#000000;border-radius:0px 0pt 0pt 0px;width:100%;background-color:rgba(0, 0, 0, 0);"><table style="padding:0mm;"><tbody><tr><td class="ui-resizable" style="padding:1mm;border-bottom-width:1pt;border-bottom-style:solid;border-bottom-color:#000000;height:56.4409px;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><strong>PATIENT STATUS AT TIME OF SERVICE OR WHEN SPECIMEN COLLECTED</strong>
<br />
<div class="k-table-wrapper" contenteditable="true" style="width:100%;border-radius:0px;background-color:rgba(0, 0, 0, 0);"><table style="display:table;padding:0mm;"><tbody><tr><td class="ui-resizable" style="width:4.01786%;padding:0mm;"> </td>
<td class="ui-resizable" style="width:78.5714%;padding:0mm;"> </td>
<td class="ui-resizable" style="width:8.48214%;padding:0mm;"><div contenteditable="true"><div style="text-align:center;"><span style="color:inherit;font-size:inherit;font-style:inherit;font-variant:inherit;font-weight:inherit;text-align:center;background-color:rgba(0, 0, 0, 0);">Yes</span>
</div></div></td>
<td class="ui-resizable" style="padding:0mm;"><div contenteditable="true"><div style="text-align:center;">No
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="width:4.01786%;padding:0mm;"><div contenteditable="true">1.
<br />
<br />
</div></td>
<td class="ui-resizable" style="width:78.5714%;padding:0mm;"><div contenteditable="true">Private patient in a private hospital or approved day hospital facility
</div></td>
<td class="ui-resizable" style="width:8.48214%;padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" type="checkbox" /></span>
</div></div></td>
<td class="ui-resizable" style="padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" type="checkbox" /></span>
<br />
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="width:4.01786%;padding:0mm;"><div contenteditable="true">2.
</div></td>
<td class="ui-resizable" style="width:78.5714%;padding:0mm;"><div contenteditable="true">Private patient in a recognised hospital
</div></td>
<td class="ui-resizable" style="width:8.48214%;padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" type="checkbox" /></span>
<br />
</div></div></td>
<td class="ui-resizable" style="padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" type="checkbox" /></span>
<br />
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="width:4.01786%;padding:0mm;"><div contenteditable="true">3.
</div></td>
<td class="ui-resizable" style="width:78.5714%;padding:0mm;"><div contenteditable="true">a Medicare (public) patient in a recognised hospital
</div></td>
<td class="ui-resizable" style="width:8.48214%;padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" type="checkbox" /></span>
<br />
</div></div></td>
<td class="ui-resizable" style="padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" type="checkbox" /></span>
<br />
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="width:4.01786%;padding:0mm;"><div contenteditable="true">4.
</div></td>
<td class="ui-resizable" style="width:78.5714%;padding:0mm;"><div contenteditable="true">Outpatient of recognised hospital
</div></td>
<td class="ui-resizable" style="width:8.48214%;padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" type="checkbox" /></span>
<br />
</div></div></td>
<td class="ui-resizable" style="padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" type="checkbox" /></span>
<br />
</div></div></td>
</tr>
</tbody></table>
</div><div class="k-table-wrapper" contenteditable="true"><table><tbody><tr><td class="ui-resizable" style="width:13.8393%;height:12.5px;"><div contenteditable="true"><strong>PRIVATE</strong>
</div></td>
<td class="ui-resizable" style="width:11.1607%;padding:0mm;height:12.5px;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" type="checkbox" /></span>
</div></td>
<td class="ui-resizable" style="width:23.6607%;padding:0mm 1mm 0mm 0mm;height:12.5px;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:right;"><strong>BULK BILL</strong>
</div></div></td>
<td class="ui-resizable" style="padding:0mm;height:12.5px;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" type="checkbox" /></span>
</div></td>
</tr>
</tbody></table>
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="padding:0mm;border-top-width:1pt;border-top-style:solid;border-top-color:#000000;"><div contenteditable="true"><div class="k-table-wrapper" contenteditable="true"><table><tbody><tr><td class="ui-resizable" style="width:52.381%;"><div contenteditable="true"><img alt="" class="img-full-size" src="https://s3-ap-southeast-2.amazonaws.com/medirecords-cdn/images/letter-template/RCPA+NATA+LOGO.jpg" /></div></td>
<td class="ui-resizable" style=""><div contenteditable="true">This document is issued in accordance with NATA/RCPA accreditation requirements. Accredited Lab Number
</div></td>
</tr>
</tbody></table>
</div></div></td>
</tr>
</tbody></table>
</div></div></td>
<td class="ui-resizable" style="width:0.1443%;height:129.333px;"> </td>
<td class="ui-resizable" style="height:129.333px;"><div contenteditable="true"><div class="k-table-wrapper" contenteditable="true" style="border:1pt solid rgb(0, 0, 0);border-radius:0pt;background-color:rgba(0, 0, 0, 0);"><table style="padding:0mm;"><tbody><tr><td class="ui-resizable" style="border-bottom-width:1pt;border-bottom-style:solid;border-bottom-color:#000000;padding:0mm;height:37px;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div class="k-table-wrapper" contenteditable="true" style="border-radius:0px;background-color:rgba(0, 0, 0, 0);"><table style=""><tbody><tr><td class="ui-resizable" style="width:60.1351%;height:14.8136px;padding:1mm 0mm 0.9mm 1mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><strong>MEDICARE ASSIGNMENT</strong> (Sector 20A of the Health insurance Act 1973)
<br />
<em>I assign my right to benefits to the approved practitioner who will render the requested pathology service(s).</em>
</div></td>
<td class="ui-resizable" style="height:14.8136px;padding:1mm 0mm 0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><strong><em>PATIENT'S SIGNATURE AND DATE<br />
<br />
<br />
</em></strong>
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="width:60.1351%;height:17.3333px;"><div contenteditable="true"><div class="k-table-wrapper" contenteditable="true"><table><tbody><tr><td class="ui-resizable" style="width:36.7816%;height:17.2px;padding:0mm 0mm 0mm 1mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">PRACTITIONER'S USE ONLY
</div></td>
<td class="ui-resizable" style="height:17.2px;"><div contenteditable="true"><div class="k-table-wrapper" contenteditable="true" style="width:95.1504%;"><table><tbody><tr><td class="ui-resizable" style="border-bottom-width:1pt;border-bottom-style:solid;border-bottom-color:#000000;padding:0mm;height:13px;background-color:rgba(0, 0, 0, 0);"> </td>
</tr>
<tr><td class="ui-resizable" style="height:9.8px;"><div contenteditable="true"><div style="text-align:center;">(Reason Patient cannot sign)
</div></div></td>
</tr>
</tbody></table>
</div></div></td>
</tr>
</tbody></table>
</div></div></td>
<td class="ui-resizable" style="height:17.3333px;padding:0px 1mm 0px 0px;"> </td>
</tr>
</tbody></table>
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="padding:0mm;border-top-width:1pt;border-top-style:solid;border-top-color:#000000;height:51px;"><div contenteditable="true"><div class="k-table-wrapper" contenteditable="true" style="border-radius:0px;background-color:rgba(0, 0, 0, 0);"><table style="padding:0mm;"><tbody><tr><td class="ui-resizable" style="width:53.3784%;padding:1mm;height:40.4915px;border-right:1pt solid rgb(0, 0, 0);background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><strong>COLLECTOR TO COMPLETE:</strong>
<div class="k-table-wrapper" contenteditable="true"><table><tbody><tr><td class="ui-resizable" style="width:51.3158%;padding:0.5mm 2mm 0mm 0mm;height:41.5px;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">I certify that the blood specimen accompanying this request was drawn from the patient stated as established by direct enquiry of the patient and/or inspection of the ID wrist-band and that specimen was labelled immediately.
<br />
I have also signed the sample tube(s)
</div></td>
<td class="ui-resizable" style="height:41.5px;"><div contenteditable="true"><div class="k-table-wrapper" contenteditable="true" style="border-radius:0px;width:100%;background-color:rgba(0, 0, 0, 0);"><table><tbody><tr><td class="ui-resizable" style="height:11px;padding:2mm 0mm 1mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">NAME:
<span style="text-decoration:underline;"> </span>
</div></td>
</tr>
<tr><td class="ui-resizable" style="height:9px;padding:2mm 0mm 1mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">SIGN:
<span style="text-decoration:underline;"> </span>
</div></td>
</tr>
<tr><td class="ui-resizable" style="padding:2mm 0mm 1mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">TIME:
<span style="text-decoration:underline;"> </span> DATE:
<span style="text-decoration:underline;"> </span>
</div></td>
</tr>
</tbody></table>
</div></div></td>
</tr>
</tbody></table>
</div></div></td>
<td class="ui-resizable" style="width:10.5856%;padding:1mm 0mm 0mm;height:40.4915px;border-right:1pt solid rgb(0, 0, 0);border-left:1pt solid rgb(0, 0, 0);background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;">ACC
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
</div></div></td>
<td class="ui-resizable" style="width:14.6396%;height:40.4915px;padding:0mm;border-right:1pt solid rgb(0, 0, 0);border-left:1pt solid rgb(0, 0, 0);"><div contenteditable="true"><div class="k-table-wrapper" contenteditable="true" style="border-radius:0px;width:100%;background-color:rgba(0, 0, 0, 0);"><table style="padding:2mm 1mm;"><tbody><tr><td class="ui-resizable" style="padding:2mm 1mm 1mm;height:13px;"><div><div class="k-table-wrapper" contenteditable="true"><table style="display:table;"><tbody><tr><td class="ui-resizable" style="width:22.6415%;"><div contenteditable="true"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" type="checkbox" /></span>
</div></td>
<td class="ui-resizable" style="width:24.5283%;"><div contenteditable="true">F
</div></td>
<td class="ui-resizable" style="width:24.5283%;"><div contenteditable="true"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" type="checkbox" /></span>
</div></td>
<td class="ui-resizable" style=""><div contenteditable="true">NF
</div></td>
</tr>
</tbody></table>
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="padding:2mm 1mm 1mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">TOLM:
<span style="text-decoration:underline;"> </span>
</div></td>
</tr>
<tr><td class="ui-resizable" style="padding:2mm 1mm 1mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">TOLD:
<span style="text-decoration:underline;"> </span>
</div></td>
</tr>
</tbody></table>
</div></div></td>
<td class="ui-resizable" style="padding:1mm 0mm 0mm 1mm;height:40.4915px;border-left-width:1pt;border-left-style:solid;border-left-color:#000000;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true">SPECIMENS::
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
</div></td>
</tr>
</tbody></table>
</div></div></td>
</tr>
</tbody></table>
</div></div></td>
</tr>
</tbody></table>
</div></span>
<span style="font-family:Arial, Helvetica, sans-serif;font-size:5pt;"><div class="k-table-wrapper" contenteditable="true"><table><tbody><tr><td class="ui-resizable" style="width:33.91053%;height:69.678px;"><div contenteditable="true"><div class="k-table-wrapper" contenteditable="true" style="border-top-width:1pt;border-top-style:solid;border-top-color:#000000;border-left-width:1pt;border-left-style:solid;border-left-color:#000000;border-bottom-width:1pt;border-bottom-style:solid;border-bottom-color:#000000;border-right-width:1pt;border-right-style:solid;border-right-color:#000000;border-radius:0px 0pt 0pt 0px;width:100%;background-color:rgba(0, 0, 0, 0);"><table style="padding:0mm;"><tbody><tr><td class="ui-resizable" style="padding:1mm;height:56.4409px;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><strong>PATIENT STATUS AT TIME OF SERVICE OR WHEN SPECIMEN COLLECTED</strong>
<br />
<div class="k-table-wrapper" contenteditable="true" style="width:100%;border-radius:0px;background-color:rgba(0, 0, 0, 0);"><table style="display:table;padding:0mm;"><tbody><tr><td class="ui-resizable" style="width:4.09091%;padding:0mm;"> </td>
<td class="ui-resizable" style="width:78.6364%;padding:0mm;"> </td>
<td class="ui-resizable" style="width:8.18182%;padding:0mm;"><div contenteditable="true"><div style="text-align:center;"><span style="color:inherit;font-size:inherit;font-style:inherit;font-variant:inherit;font-weight:inherit;text-align:center;background-color:rgba(0, 0, 0, 0);">Yes</span>
</div></div></td>
<td class="ui-resizable" style="padding:0mm;"><div contenteditable="true"><div style="text-align:center;">No
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="width:4.09091%;padding:0mm;"><div contenteditable="true">1.
<br />
<br />
</div></td>
<td class="ui-resizable" style="width:78.6364%;padding:0mm;"><div contenteditable="true">Private patient in a private hospital or approved day hospital facility
</div></td>
<td class="ui-resizable" style="width:8.18182%;padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" name="" style="margin:0;" type="checkbox" /></span>
</div></div></td>
<td class="ui-resizable" style="padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" name="" style="margin:0;" type="checkbox" /></span>
<br />
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="width:4.09091%;padding:0mm;"><div contenteditable="true">2.
</div></td>
<td class="ui-resizable" style="width:78.6364%;padding:0mm;"><div contenteditable="true">Private patient in a recognised hospital
</div></td>
<td class="ui-resizable" style="width:8.18182%;padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" name="" style="margin:0;" type="checkbox" /></span>
<br />
</div></div></td>
<td class="ui-resizable" style="padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" name="" style="margin:0;" type="checkbox" /></span>
<br />
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="width:4.09091%;padding:0mm;"><div contenteditable="true">3.
</div></td>
<td class="ui-resizable" style="width:78.6364%;padding:0mm;"><div contenteditable="true">a Medicare (public) patient in a recognised hospital
</div></td>
<td class="ui-resizable" style="width:8.18182%;padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" name="" style="margin:0;" type="checkbox" /></span>
<br />
</div></div></td>
<td class="ui-resizable" style="padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" name="" style="margin:0;" type="checkbox" /></span>
<br />
</div></div></td>
</tr>
<tr><td class="ui-resizable" style="width:4.09091%;padding:0mm;"><div contenteditable="true">4.
</div></td>
<td class="ui-resizable" style="width:78.6364%;padding:0mm;"><div contenteditable="true">Outpatient of recognised hospital
</div></td>
<td class="ui-resizable" style="width:8.18182%;padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" name="" style="margin:0;" type="checkbox" /></span>
<br />
</div></div></td>
<td class="ui-resizable" style="padding:0mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" name="" style="margin:0;" type="checkbox" /></span>
<br />
</div></div></td>
</tr>
</tbody></table>
</div><div class="k-table-wrapper" contenteditable="true"><table><tbody><tr><td class="ui-resizable" style="width:14.0909%;height:12.5px;"><div contenteditable="true"><strong>PRIVATE</strong>
</div></td>
<td class="ui-resizable" style="width:10.9091%;padding:0mm;height:12.5px;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" name="" style="margin:0;" type="checkbox" /></span>
</div></td>
<td class="ui-resizable" style="width:23.6364%;padding:0mm 1mm 0mm 0mm;height:12.5px;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:right;"><strong>BULK BILL</strong>
</div></div></td>
<td class="ui-resizable" style="padding:0mm;height:12.5px;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><span class="editableitem" contenteditable="true"><input class="mr-custom-field custom-checkbox" name="" style="margin:0;" type="checkbox" /></span>
</div></td>
</tr>
</tbody></table>
</div></div></td>
</tr>
</tbody></table>
</div></div></td>
<td class="ui-resizable" style="width:0.8658%;height:69.678px;"> </td>
<td class="ui-resizable" style="height:69.678px;"><div contenteditable="true"><span style="font-size:xx-small;"><div class="k-table-wrapper" contenteditable="true" style="border-radius:0pt;border:1pt solid rgb(0, 0, 0);background-color:rgba(0, 0, 0, 0);"><table style="padding:0mm;"><tbody><tr><td class="ui-resizable" style="width:55.9551%;height:14.8136px;padding:0mm 2mm 0mm 1mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><strong>MEDICARE ASSIGNMENT<br />
</strong>(Sector 20A of the Health insurance Act 1973)
<br />
<br />
<em>I assign my right to benefits to the approved practitioner who will render the requested pathology service(s).</em>
</div></td>
<td class="ui-resizable" style="height:14.8136px;padding:3.7mm 1mm 3.8mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><div style="text-align:center;"><strong><em>PATIENT'S SIGNATURE AND DATE<br />
<br />
<br />
<br />
<br />
<br />
<div class="k-table-wrapper" contenteditable="true"><table><tbody><tr><td class="ui-resizable" style="padding:0mm;border-bottom-width:1pt;border-bottom-style:solid;border-bottom-color:#000000;background-color:rgba(0, 0, 0, 0);"> </td>
</tr>
</tbody></table>
</div></em></strong>
</div></div></td>
</tr>
</tbody></table>
</div></span>
</div></td>
</tr>
</tbody></table>
</div></span></span>
Radiology Request Template:
HTML Code to be copied (per step 1)
<div class="k-table-wrapper" contenteditable="true"><table><tbody><tr><td class="style1 ui-resizable"><div contenteditable="true"><div class="style3" style="width:1199px;"><span class="style2" style="font-family:Arial, Helvetica, sans-serif;color:#003399;font-size:18pt;">IMAGING REQUEST</span>
<span class="style2" style="font-family:Arial, Helvetica, sans-serif;color:#003399;"><br />
<span style="color:#003399;font-family:Arial, Helvetica, sans-serif;font-size:16px;background-color:#ffffff;">{addressee.all-contact-details}<br />
{addressee.office-phone}<br />
</span><br />
</span><br class="style4" /></div></div></td>
</tr>
<tr><td class="style1 ui-resizable"> </td>
</tr>
</tbody></table>
</div><div class="k-table-wrapper" contenteditable="true" style="border-radius:0px;background-color:rgba(0, 0, 0, 0);"><table style="padding:0mm;"><tbody><tr><td class="ui-resizable" style="padding:0mm;"><div contenteditable="true"><div class="k-table-wrapper" contenteditable="true" style="border-radius:10pt;border:1.5pt solid rgb(60, 76, 160);background-color:rgba(0, 0, 0, 0);"><table style="padding:0mm;"><tbody><tr><td class="ui-resizable" style="padding:1mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><p><span style="color:#003399;font-family:Arial, Helvetica, sans-serif;font-size:12pt;"> Patient Details<br />
</span><br />
<span style="color:#003399;font-family:Arial, Helvetica, sans-serif;font-size:10pt;">Name <br />
</span> <span style="color:#000000;">{patient.full-name}<br />
<span style="background-color:#ffffff;">DOB: {patient.DOB}</span><br />
</span><br />
<span style="color:#003399;font-family:Arial, Helvetica, sans-serif;font-size:10pt;"> Address</span><br />
{patient.full-address}<br />
<br />
<span style="color:#003399;font-family:Arial, Helvetica, sans-serif;font-size:10pt;"> Medicare Number<br />
</span> {patient-settings.medicare-number}<br />
<br />
</p>
</div></td>
</tr>
</tbody></table>
</div><br />
<div class="k-table-wrapper" contenteditable="true" style="border-radius:10pt;border:1.5pt solid rgb(60, 76, 160);background-color:rgba(0, 0, 0, 0);"><table style="padding:0mm;"><tbody><tr><td class="ui-resizable" style="padding:1mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"> <span style="color:#003399;font-family:Arial, Helvetica, sans-serif;font-size:12pt;">Examination(s) Requested<br />
<br />
</span><span style="color:#000000;font-family:Arial, Helvetica, sans-serif;font-size:10pt;"> {investigation-request.radiology-requests}</span><span style="color:#003399;font-family:Arial, Helvetica, sans-serif;font-size:12pt;"><br />
<br />
<br />
<br />
<br />
<br />
<br />
</span></div></td>
</tr>
</tbody></table>
</div><br />
<div class="k-table-wrapper" contenteditable="true" style="border:1.5pt solid rgb(60, 76, 160);border-radius:10pt;background-color:rgba(0, 0, 0, 0);"><table style="padding:0mm;"><tbody><tr><td class="ui-resizable" style="padding:0mm;"><div contenteditable="true"> <span style="color:#003399;font-family:Arial, Helvetica, sans-serif;font-size:12pt;">Clinical Notes<br />
</span><br />
{investigation-request.radiology-clinical-findings}<br />
<br />
<br />
<br />
<br />
<br />
<span style="color:#003399;font-family:Arial, Helvetica, sans-serif;font-size:12pt;"><br />
<br />
</span></div></td>
</tr>
</tbody></table>
</div><br />
<div class="k-table-wrapper" contenteditable="true" style="border:1.5pt solid rgb(60, 76, 160);border-radius:10pt;background-color:rgba(0, 0, 0, 0);"><table style="padding:0mm;"><tbody><tr><td class="ui-resizable" style="padding:1mm;background-color:rgba(0, 0, 0, 0);"><div contenteditable="true"><span style="color:#003399;font-family:Arial, Helvetica, sans-serif;font-size:12pt;"> Referring Doctor<br />
</span><br />
<span style="color:#333399;font-size:10pt;font-family:Arial, Helvetica, sans-serif;">Name</span><br />
<span style="color:#000000;font-size:10pt;font-family:Arial, Helvetica, sans-serif;">{current-user.full-name}</span><br />
<span style="font-size:10pt;font-family:Arial, Helvetica, sans-serif;"> {practice.address}</span><br />
<span style="font-size:10pt;font-family:Arial, Helvetica, sans-serif;"> {current-user.provider-no}<br />
</span><br />
<div class="k-table-wrapper" contenteditable="true"><table><tbody><tr><td class="ui-resizable" style="width:50%;"><div contenteditable="true"> <span style="color:#003399;font-size:10pt;font-family:Arial, Helvetica, sans-serif;">Phone Number </span><span style="color:#000000;font-size:10pt;font-family:Arial, Helvetica, sans-serif;">{current-user.office-phone}</span></div></td>
<td class="ui-resizable" style=""><div contenteditable="true"><span style="color:#003399;font-size:10pt;font-family:Arial, Helvetica, sans-serif;">Fax Number </span><span style="color:#000000;font-size:10pt;font-family:Arial, Helvetica, sans-serif;">{practice.fax}</span></div></td>
</tr>
</tbody></table>
</div> <br />
<span style="color:#333399;font-family:Arial, Helvetica, sans-serif;font-size:13.3333px;background-color:#ffffff;"> Copies to:<br />
</span> {investigation-request.copies-to}<br />
<br />
<br />
<br />
<br />
<div class="k-table-wrapper" contenteditable="true"><table><tbody><tr><td class="ui-resizable" style="width:50%;"><div contenteditable="true"><span style="color:#003399;font-family:Arial, Helvetica, sans-serif;font-size:10pt;"> Signed</span></div></td>
<td class="ui-resizable" style=""><div contenteditable="true"><span style="color:#003399;font-family:Arial, Helvetica, sans-serif;font-size:10pt;">Date </span><span style="color:#000000;font-family:Arial, Helvetica, sans-serif;font-size:10pt;">{general.todays-date}</span></div></td>
</tr>
</tbody></table>
</div><br />
</div></td>
</tr>
</tbody></table>
</div><div class="k-table-wrapper" contenteditable="false"></div><div class="k-table-wrapper" contenteditable="false"></div></div></td>
</tr>
</tbody></table>
</div><br />
<br />
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