$LDRequestTo
$formtitle   $LDDepartment

$TP_checkbox_1   $LDVisitRequested

$TP_checkbox_2   $LDPatCanBeOrdered

$batch_nr 
$TP_img_barcode

$TP_img_patient_label
$LDDiagnosesInquiries
$TP_vspacer_1 <$TP_block_1> $TP_diagnosis_quiry

$LDDate : $TP_send_date $TP_calender_1
$LDDoctor <$TP_input_1 type="text" name="send_doctor" size=40 maxlength=40 value="$TP_send_doctor"> $TP_send_doctor_x     
 
$LDDeptReport
$TP_vspacer_2 <$TP_block_2 name="result" cols=80 rows=10 wrap="physical">$TP_result

$LDDate : $TP_report_date $TP_calendar_2
$LDDoctor <$TP_input_2 type="text" name="result_doctor" size=40 maxlength=40 value="$TP_result_doctor"> $TP_result_doctor_x