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  • Requisition and Issue Slip

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    rhane_freefall
    25 vues4 pages
    Example of coeds on how to make a Requisition and Issue Slip

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    Example of coeds on how to make a Requisition and Issue Slip

    Droits d'auteur :

    Attribution Non-Commercial (BY-NC)
    Téléchargez comme TXT, PDF, TXT ou lisez en ligne sur Scribd
    Signaler comme contenu inapproprié
    25 vues4 pages

    Requisition and Issue Slip

    Transféré par

    rhane_freefall
    Example of coeds on how to make a Requisition and Issue Slip

    Droits d'auteur :

    Attribution Non-Commercial (BY-NC)
    Téléchargez comme TXT, PDF, TXT ou lisez en ligne sur Scribd
    Signaler comme contenu inapproprié
    sur 4

    <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.

    01 Transitional//EN"
    "http://www.w3.org/TR/html4/loose.dtd">
    <html>
    <head>
    <title>Untitled Document</title>
    <meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1">
    </head>

    <body>
    <center>
    <p><font size="+2">Requisition and Issue Slip</font></p>
    <p>&nbsp;</p>
    <form name="form1" method="post" action="">
    <div align="left">
    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&
    nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&
    nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;

    <input name="radiobutton" type="radio" value="radiobutton">


    Pharmacy
    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
    &nbsp;&nbsp;&nbsp;
    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
    <input name="radiobutton" type="radio" value="radiobutton">
    Medical Mission
    </div>
    </form>

    </center>
    <div align="left">
    <p>&nbsp;</p>
    <p>Date :
    <input name="Date" type="text" value="" size="30" maxlength="50">

    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
    &nbsp;&nbsp;
    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
    &nbsp;&nbsp;
    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
    &nbsp;&nbsp;
    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
    &nbsp;&nbsp;
    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
    &nbsp;&nbsp;
    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
    &nbsp;&nbsp;
    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
    &nbsp;&nbsp;
    RIS No. : <input name="RIS No." type="text" size="25" maxlength="50">
    </p>
    <p>&nbsp;</p>
    <p>ID No. : <input name="IDNo." type="text" size="5" maxlength="15"><input
    name="IDNo." type="text" size="5" maxlength="15"> -
    <input name="IDNo." type="text" size="5" maxlength="15"><input name="IDNo."
    type="text" size="5" maxlength="15"><input name="IDNo." type="text" size="5"
    maxlength="15"><input name="IDNo." type="text" size="5" maxlength="15"> -
    <input name="IDNo." type="text" size="5" maxlength="15"><input name="IDNo."
    type="text" size="5" maxlength="15">
    </p>
    <p>&nbsp;</p>
    <p>Name of Patient : <input name="Nameofpatient" type="text" size="100"
    maxlength="50"></p>
    <p>&nbsp;</p>
    <table width="905" border="1">
    <tr>
    <td width="427"><div align="center">Requisition</div></td>
    <td width="462"><div align="center">Issued</div></td>
    </tr>
    </table>

    <table width="905" border="1">


    <tr>
    <td width="88"><center>MedCode</center></td>
    <td width="244"><center>Description</center></td>
    <td width="82"><center>Quantity</center></td>
    <td width="101"><center>Quantity</center></td>
    <td width="96"><center>Unit Cost</center> </td>
    <td width="254"><center>
    Total Cost
    </center></td>
    </tr>
    <tr>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
    </tr>
    <tr>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
    </tr>
    <tr>
    <td>&nbsp;</td>

    <td>&nbsp;</td>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
    </tr>
    <tr>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
    </tr>
    <tr>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
    </tr>
    <tr>
    <td colspan="2">Total</td>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
    </tr>
    </table>
    <p>&nbsp;</p>
    <table width="906" border="1">
    <tr>
    <td width="178">Approved for Issuance by : </td>
    <td width="712">&nbsp;</td>
    </tr>
    </table>
    <p>&nbsp;</p>
    <table width="905" border="1">
    <tr>
    <td width="181">Issued by : </td>
    <td width="708">&nbsp;</td>
    </tr>
    </table>
    <p>&nbsp;</p>
    <form name="form2" method="post" action="">
    <input type="submit" name="Save" value="Save">
    <input type="submit" name="Edit" value="Edit">
    <input type="submit" name="Cancel" value="Cancel">
    <input type="submit" name="Exit " value="Exit">
    </form>
    <p>&nbsp;</p>
    <p>&nbsp;</p>
    <p>&nbsp;</p>
    <p>&nbsp;</p>
    <p>&nbsp;</p>
    <p>&nbsp;</p>
    <p>&nbsp;</p>
    </div>
    </body>
    </html>

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