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Adding a Logo to the Generic Pathology or Radiology Template

MediRecords provides users with generic non-branded pathology and generic radiology templates, designed so that the patient can take their request form to any company.

You may wish to add your own logo or signature to help personalise these templates. This article will step you through this process.

 

Copy the HTML code

Firstly, you will need to copy the html code contained in the text box contained at the bottom of this page. Please use the html code specific to the type of template i.e either Pathology or Radiology. Highlight all of the text within the relevant box, then either right click and choose Copy, or hold down Ctrl/Cmd and C on the keyboard.

 

Create Your Template in MediRecords:

Go to More > Resources, Letter Templates, then click New Template.
In the Save window that pops up, select the following.
Category = Letter
Type = Investigations
Sharing = Practice
Then, give your template a desired Name and Description.
Click Save.

 

Paste in the HTML code

Click the View HTML button, which looks like the less than and greater than symbols, separated by a forward slash.

In the View HTML box, right-click your mouse, then choose Paste (or Ctrl/Cmd and P on the keyboard) and the HTML code you had copied earlier should now appear. Click Update.

2255F507-572F-4A50-8F8B-EBB98CFFF8B2.GIF

*NOTE: Any text within curly brackets ({}) is a mail merge field. These are designed to populate the patient's details, the tests you've ordered, and other important information; please do not edit anything within these.

Adding your logo

Place your cursor in the template where you would like the image to appear. Then click the Insert Image button, as seen here.

Either select a pre-existing image or click Upload to add a new image.

Click Insert to add the image to the template.


Some users find it easier to insert the image within a table, to help give the image a designated place to go. Our generic pathology request template already contains a table for the header, so in the example below, we've added a column for the logo to sit on the right, by using the Add column on the right button. 

If your template doesn't have a table, you can use the Create a table button to make a 1 x 1 table.

A demonstration of the overall process is below:

183ED319-02FB-41C7-89B5-2E3E833650FB.GIF

 

You may also wish to try using left or right alignment, the Enter key, or the Backspace key to move the text, tables, or logo, up and down.

You have now completed your custom pathology/radiology template. Next, you'll need to assign the template to the desired companies. 

 

HTML Code to be copied (per step 1).

Pathology Request Template:

<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);">&nbsp;</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}&nbsp;{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:&nbsp;{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:&nbsp;{investigation-request.site-desc}&nbsp;{investigation-request.pregnancy-desc}&nbsp;{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:&nbsp;
<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:&nbsp;{investigation-request.urgent-phone} /&nbsp;{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);">&nbsp;</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:&nbsp;{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;">&nbsp;</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>&nbsp; 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">&nbsp; &nbsp; &nbsp; &nbsp; 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">&nbsp; &nbsp; &nbsp; &nbsp; 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">&nbsp; &nbsp; &nbsp; &nbsp; 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:&nbsp;{practice.office-phone} &nbsp; &nbsp; &nbsp;Fax:&nbsp;{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;">&nbsp;</td>
<td class="ui-resizable" style="width:78.5714%;padding:0mm;">&nbsp;</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;">&nbsp;</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);">&nbsp;</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;">&nbsp;</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:&nbsp;
<span style="text-decoration:underline;">&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</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:&nbsp;
<span style="text-decoration:underline;">&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</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;"> &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</span>&nbsp; DATE:&nbsp;
<span style="text-decoration:underline;">&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</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:&nbsp;
<span style="text-decoration:underline;"> &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</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:&nbsp;
<span style="text-decoration:underline;"> &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; </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;">&nbsp;</td>
<td class="ui-resizable" style="width:78.6364%;padding:0mm;">&nbsp;</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;">&nbsp;</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 />
&nbsp;<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);">&nbsp;</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:

<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">&nbsp;</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;">&nbsp;Patient Details<br />
</span><br />
&nbsp;<span style="color:#003399;font-family:Arial, Helvetica, sans-serif;font-size:10pt;">Name&nbsp;<br />
</span>&nbsp;<span style="color:#000000;">{patient.full-name}<br />
&nbsp;<span style="background-color:#ffffff;">DOB:&nbsp;{patient.DOB}</span><br />
</span><br />
<span style="color:#003399;font-family:Arial, Helvetica, sans-serif;font-size:10pt;">&nbsp;Address</span><br />
&nbsp;{patient.full-address}<br />
<br />
<span style="color:#003399;font-family:Arial, Helvetica, sans-serif;font-size:10pt;">&nbsp;Medicare Number<br />
</span>&nbsp;{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">&nbsp;<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;">&nbsp;{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">&nbsp;<span style="color:#003399;font-family:Arial, Helvetica, sans-serif;font-size:12pt;">Clinical Notes<br />
</span><br />
&nbsp; {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;">&nbsp;Referring Doctor<br />
</span><br />
&nbsp;<span style="color:#333399;font-size:10pt;font-family:Arial, Helvetica, sans-serif;">Name</span><br />
&nbsp;<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;">&nbsp;{practice.address}</span><br />
<span style="font-size:10pt;font-family:Arial, Helvetica, sans-serif;">&nbsp;{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">&nbsp;<span style="color:#003399;font-size:10pt;font-family:Arial, Helvetica, sans-serif;">Phone Number&nbsp;</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&nbsp;</span><span style="color:#000000;font-size:10pt;font-family:Arial, Helvetica, sans-serif;">{practice.fax}</span></div></td>
</tr>
</tbody></table>
</div>&nbsp;<br />
<span style="color:#333399;font-family:Arial, Helvetica, sans-serif;font-size:13.3333px;background-color:#ffffff;">&nbsp;Copies to:<br />
</span>&nbsp;{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;">&nbsp;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&nbsp;</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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