NINS_CODE/bahmni_config/openmrs/apps/registration/admissionFormLayout/print.html

<link rel="stylesheet" href="/bahmni_config/openmrs/apps/registration/admissionFormLayout/css/bootstrap.min.css"/>
<link rel="stylesheet" href="/bahmni_config/openmrs/apps/registration/admissionFormLayout/css/style.css"/>
<div class="container">
    <div class="row" style="margin-top:5px">
        <div class="col-md-8">
            <span>Patient ID / Reg. No.</span>
            <span>....................................................................................................................................</span>
        </div>
        <div class="col-md-4">
            <span>Cabin/Ward</span>
            <span>...........................................................................</span>
        </div>
    </div>

    <div class="row" style="margin-top:5px">
        <div class="col-md-8">
            <span>Staff / Health Card ID</span>
            <span>..................................................................................................................................</span>
        </div>
        <div class="col-md-4">
            <span>Bed No.</span>
            <span>...................................................................................</span>
        </div>
    </div>
    <div class="row" style="margin-top:5px">
        <div class="col-md-8">
            <span>Patient Name</span>
            <span>..................................................................................................................................................</span>
        </div>
        <div class="col-md-4">
            <span>Sex</span>
            <span>............................................................................................</span>
        </div>
    </div>
    <div class="row" style="margin-top:5px">
        <div class="col-md-8">
            <span>Age</span>
            <span>......................................................................................................................................................................</span>
        </div>
        <div class="col-md-4">
            <span>Blood Group</span>
            <span>.........................................................................</span>
        </div>
    </div>
    <div class="row" style="margin-top:5px">
        <div class="col-md-8">
            <span>Occupation</span>
            <span>.......................................................................................................................................................</span>
        </div>
        <div class="col-md-4">
            <span>Contact No</span>
            <span>............................................................................</span>
        </div>
    </div>

    <div class="row" style="margin-top:5px">
        <div class="col-md-12">
            <span>Fathers/Husband Name</span>
            <span>..............................................................................................................................</span>
        </div>
    </div>
    <div class="row" style="margin-top:5px">
        <div class="col-md-12">
            <span>Mothers Name</span>
            <span>...............................................................................................................................................</span>
        </div>
    </div>


    <div class="row" style="margin-top:15px">
        <div class="col-md-4">
            <span>Present Adress</span>
        </div>
        <div class="col-md-4">
            <span>Village</span>
            <span>...................................................</span>
        </div>
        <div class="col-md-4">
            <span>P.O</span>
            <span>................................................................</span>
        </div>
    </div>

    <div class="row" style="margin-top:5px">
        <div class="col-md-4">
            <span></span>
        </div>
        <div class="col-md-4">
            <span>P.S</span>
            <span>..........................................................</span>
        </div>
        <div class="col-md-4">
            <span>District</span>
            <span>.........................................................</span>
        </div>
    </div>

    <div class="row" style="margin-top:15px">
        <div class="col-md-4">
            <span>Permanent Address</span>
        </div>
        <div class="col-md-4">
            <span>Village</span>
            <span>...................................................</span>
        </div>
        <div class="col-md-4">
            <span>P.O</span>
            <span>................................................................</span>
        </div>
    </div>

    <div class="row" style="margin-top:5px">
        <div class="col-md-4">
            <span></span>
        </div>
        <div class="col-md-4">
            <span>P.S</span>
            <span>..........................................................</span>
        </div>
        <div class="col-md-4">
            <span>District</span>
            <span>.........................................................</span>
        </div>
    </div>
    <div class="row" style="margin-top:10px">
        <div class="col-md-12">
            <span><b>Emergency Contact Name</b> : </span>
            <span>....................................................................................................................</span>
        </div>
    </div>
    <div class="row" style="margin-top:5px">
        <div class="col-md-12">
            <span>Phone : </span>
            <span>................................................................................................................................................................</span>
        </div>
    </div>
    <div class="row" style="margin-top:5px">
        <div class="col-md-12">
            <span>Diagnosis : </span>
            <span>.........................................................................................................................................................</span>
        </div>
    </div>

    <div class="row" style="margin-top:5px">
        <div class="col-md-12">
            <span>...............................................................................................................................................................................................................................................................................................................................</span>
        </div>
    </div>
    <div class="row" style="margin-top:5px">
        <div class="col-md-12">
            <span>Attending Doctor’s Name</span>
            <span>..........................................................................................................................................................................................................................................................................</span>
        </div>
    </div>
    <div class="row" style="margin-top:5px">
        <div class="col-md-8">
            <span>Consultant Name : </span>
            <span>.........................................................................................................................................</span>
        </div>
        <div class="col-md-4">
            <span>(Emergency) : </span>
            <span>.......................................................................</span>
        </div>
    </div>
    <div class="row" style="margin-top:5px">
        <div class="col-md-8">
            <span>Date of Admission : </span>
            <span>........................................................................................................................................</span>
        </div>
        <div class="col-md-4">
            <span>Time : </span>
            <span>......................................................................................</span>
        </div>
    </div>
    <div class="row" style="margin-top:5px">
        <div class="col-md-8">
            <span>Date of Discharge : </span>
            <span>........................................................................................................................................</span>
        </div>
        <div class="col-md-4">
            <span>Time : </span>
            <span>......................................................................................</span>
        </div>
    </div>
    <div class="row" style="margin-top:5px">
        <div class="col-md-8">
            <span>Date of Surgery : </span>
            <span>.............................................................................................................................................</span>
        </div>
        <div class="col-md-4">
            <span>Time : </span>
            <span>......................................................................................</span>
        </div>
    </div>

    <div class="row" style="margin-top:20px">
        <div class="col-md-8">
            <table style="width:50%;>
		  <tr>
			<th colspan=">Mode of Discharge</th>
                </tr>
                <tr>
                    <td></td>
                </tr>
            </table>
        </div>
        <div class="col-md-4">
            <span><b>Signature : </b></span>
            <span>..........................................................................</span>
        </div>
    </div>
    <div class="row" style="margin-top:15px">
        <div class="col-md-8">

            <span></span>
        </div>
        <div class="col-md-4">
            <span>Name : </span>
            <span>...................................................................................</span>
        </div>
    </div>
    <div class="row" style="margin-top:5px">
        <div class="col-md-8">
            <span></span>
        </div>
        <div class="col-md-4">
            <span>Date : </span>
            <span>......................................................................................</span>
        </div>
    </div>
</div>