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File: formulir alih dpjp.html
<html> <head> <meta http-equiv="Content-Type" content="text/html; charset=UTF-8"> <style type="text/css"> .txt { white-space:nowrap; } #f0 { font-family:sans-serif; font-weight:normal; font-style:normal; } #f1 { font-family:sans-serif; font-weight:bold; font-style:normal; } #f2 { font-family:sans-serif; font-weight:normal; font-style:normal; } @font-face { font-family: ff0; src: url("0.ttf"); } #f3 { font-family:ff0,monospace; font-weight:normal; font-style:normal; } @font-face { font-family: ff1; src: url("1.ttf"); } #f4 { font-family:ff1,sans-serif; font-weight:normal; font-style:normal; } #f5 { font-family:monospace; font-weight:normal; font-style:normal; } </style> </head> <body> <img id="background" style="position:absolute; left:0px; top:0px;" width="595" height="841" src="page1.png"> <div class="txt" style="position:absolute; left:239px; top:3px;"><span id="f1" style="font-size:15px;vertical-align:baseline;color:rgba(0,175,80,1);">RUMAH SAKIT</span></div> <div class="txt" style="position:absolute; left:265px; top:23px;"><span id="f1" style="font-size:20px;vertical-align:baseline;color:rgba(255,0,0,1);">AULIA</span></div> <div class="txt" style="position:absolute; left:262px; top:43px;"><span id="f2" style="font-size:9px;vertical-align:baseline;color:rgba(4,98,193,1);">www.rsaulia.com</span></div> <div class="txt" style="position:absolute; left:162px; top:55px;"><span id="f2" style="font-size:9px;vertical-align:baseline;color:rgba(0,0,0,1);">Alamat : Jalan Jeruk Raya No. 15, Jagakarsa, Jakarta Selatan 12620</span></div> <div class="txt" style="position:absolute; left:246px; top:66px;"><span id="f2" style="font-size:9px;vertical-align:baseline;color:rgba(0,0,0,1);">Email : info@rsaulia.com</span></div> <div class="txt" style="position:absolute; left:234px; top:78px;"><span id="f2" style="font-size:9px;vertical-align:baseline;color:rgba(0,0,0,1);">Telp : (021) 7270208; 7866057</span></div> <div class="txt" style="position:absolute; left:455px; top:22px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">No Form : FR.RI.112-22</span></div> <div class="txt" style="position:absolute; left:453px; top:42px;"><span id="f2" style="font-size:10px;vertical-align:baseline;color:rgba(0,0,0,1);">No Rev : 00</span></div> <div class="txt" style="position:absolute; left:135px; top:135px;"><span id="f1" style="font-size:12px;vertical-align:baseline;color:rgba(0,0,0,1);">FORMULIR DPJP</span></div> <div class="txt" style="position:absolute; left:77px; top:187px;"><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">Tanggal :</span></div> <div class="txt" style="position:absolute; left:77px; top:209px;"><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">Status : </span><span id="f4" style="font-size:12px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">BPJS</span></div> <div class="txt" style="position:absolute; left:218px; top:209px;"><span id="f4" style="font-size:12px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">Umum</span></div> <div class="txt" style="position:absolute; left:77px; top:230px;"><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">Diagnosa Medis :</span></div> <div class="txt" style="position:absolute; left:95px; top:251px;"><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">1. .............................................</span></div> <div class="txt" style="position:absolute; left:95px; top:272px;"><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">2. .............................................</span></div> <div class="txt" style="position:absolute; left:95px; top:292px;"><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">3. .............................................</span></div> <div class="txt" style="position:absolute; left:95px; top:313px;"><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">4. ............................................</span></div> <div class="txt" style="position:absolute; left:77px; top:334px;"><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">DPJP :</span></div> <div class="txt" style="position:absolute; left:303px; top:104px;"><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">NAMA</span></div> <div class="txt" style="position:absolute; left:396px; top:104px;"><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">:</span></div> <div class="txt" style="position:absolute; left:303px; top:125px;"><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">NO. RM</span></div> <div class="txt" style="position:absolute; left:396px; top:125px;"><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">:</span></div> <div class="txt" style="position:absolute; left:303px; top:145px;"><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">TGL LAHIR :</span></div> <div class="txt" style="position:absolute; left:303px; top:166px;"><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">JENIS KELAMIN : L / P</span></div> <div class="txt" style="position:absolute; left:303px; top:187px;"><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">Jam :</span></div> <div class="txt" style="position:absolute; left:358px; top:209px;"><span id="f4" style="font-size:12px;vertical-align:baseline;color:rgba(0,0,0,1);"> </span><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">Asuransi ...........</span></div> <div class="txt" style="position:absolute; left:303px; top:334px;"><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">TANDA TANGAN :</span></div> <div class="txt" style="position:absolute; left:130px; top:376px;"><span id="f1" style="font-size:12px;vertical-align:baseline;color:rgba(0,0,0,1);">RAWAT BERSAMA</span></div> <div class="txt" style="position:absolute; left:379px; top:376px;"><span id="f1" style="font-size:12px;vertical-align:baseline;color:rgba(0,0,0,1);">TANGGAL</span></div> <div class="txt" style="position:absolute; left:77px; top:397px;"><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">DPJP UTAMA :</span></div> <div class="txt" style="position:absolute; left:77px; top:419px;"><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">DPJP :</span></div> <div class="txt" style="position:absolute; left:77px; top:440px;"><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">DPJP :</span></div> <div class="txt" style="position:absolute; left:77px; top:461px;"><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">DPJP</span></div> <div class="txt" style="position:absolute; left:221px; top:482px;"><span id="f1" style="font-size:12px;vertical-align:baseline;color:rgba(0,0,0,1);">PERALIHAN DPJP UTAMA</span></div> <div class="txt" style="position:absolute; left:77px; top:504px;"><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">DPJP PERALIHAN :</span></div> <div class="txt" style="position:absolute; left:303px; top:504px;"><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">TANDA TANGAN :</span></div> <div class="txt" style="position:absolute; left:77px; top:545px;"><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">TANGGAL :</span></div> <div class="txt" style="position:absolute; left:77px; top:567px;"><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">ALASAN :</span></div> <div class="txt" style="position:absolute; left:77px; top:608px;"><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">PEMOHON PASIEN :</span></div> <div class="txt" style="position:absolute; left:303px; top:608px;"><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">TTD :</span></div> <div class="txt" style="position:absolute; left:77px; top:650px;"><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">REKOMENDASI CASE MANAGER :</span></div> <div class="txt" style="position:absolute; left:303px; top:650px;"><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">TTD :</span></div> <div class="txt" style="position:absolute; left:77px; top:692px;"><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">PERSETUJUAN DPJP LAMA :</span></div> <div class="txt" style="position:absolute; left:303px; top:692px;"><span id="f2" style="font-size:11px;vertical-align:baseline;color:rgba(0,0,0,1);">TTD</span></div> </body> </html>