                <table style="margin-top: -10px; width: 100%;">
                    <tr>
                        <td style="margin-top: -10px; width: 20%;"><img src="<?= base_url('images/logo.png'); ?>" width="70" height="50"></td>
                        <td style="margin-top: -10px; width: 80%; text-align:center;">
                            <b style='font-size:18px;'><?= $abdulradjak['NamaPerusahaan']; ?></b><br>
                            <?= $abdulradjak['AlamatPerusahaan']; ?><br>
                            <small>Telp. <?= $abdulradjak['TeleponPerusahaan']; ?>, Fax : <?= $abdulradjak['FaxPerusahaan']; ?></small>
                        </td>
                    </tr>
                </table>
                <hr>
                <h3 style="text-align: center;"><u>FORMULIR PENDAFTARAN INI HARAP DI ISI DENGAN LENGKAP DAN JELAS</u></h3>
                <br>
                <table style="width:100%; hight:100%;">
                    <tr>
                        <td>NOMOR MR</td>
                        <td>:</td>
                        <td><?= $pasien['PatientCode']; ?></td>
                    </tr>
                    <tr>
                        <td>No. NIK</td>
                        <td>:</td>
                        <td><?= $pasien['NIK']; ?></td>
                    </tr>
                    <tr>
                        <td>NAMA PASIEN</td>
                        <td>:</td>
                        <td><?= $pasien['FirstName']; ?></td>
                    </tr>
                    <tr>
                        <td>TEMPAT & TANGGAL LAHIR</td>
                        <td>:</td>
                        <td><?= $pasien['DOBPlace'] . '/' . date('d-m-Y', strtotime($pasien['DOB'])); ?></td>
                    </tr>
                    <?php
                    if ($pasien['Sex'] == 1) {
                        $Jenis = "Perempuan";
                    } else {
                        $Jenis = "Laki - Laki";
                    }
                    ?>
                    <tr>
                        <td>JENIS KELAMIN</td>
                        <td>:</td>
                        <td><?= $Jenis; ?></td>
                    </tr>
                    <tr>
                        <td>STATUS</td>
                        <td>:</td>
                        <td><?= $pasien['Status']; ?></td>
                    </tr>
                    <tr>
                        <td>AGAMA</td>
                        <td>:</td>
                        <td><?= $pasien['Religion']; ?></td>
                    </tr>
                    <tr>
                        <td>ALAMAT LENGKAP</td>
                        <td>:</td>
                        <td><?= $pasien['HomeAddress1']; ?></td>
                    </tr>
                    <tr>
                        <td>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;- KELURAHAN</td>
                        <td>:</td>
                        <td><?= $pasien['Kelurahan']; ?></td>
                    </tr>
                    <tr>
                        <td>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;- KECAMATAN</td>
                        <td>:</td>
                        <td><?= $pasien['Kecamatan']; ?></td>
                    </tr>
                    <tr>
                        <td>NO. HP</td>
                        <td>:</td>
                        <td><?= $pasien['CellPhone']; ?></td>
                    </tr>
                    <tr>
                        <td>NO. ASURANSI/NO.BPJS</td>
                        <td>:</td>
                        <td><?= $pasien['EmployeeID']; ?></td>
                    </tr>
                    <tr>
                        <td>NAMA PENANGGUNG JAWAB</td>
                        <td>:</td>
                        <td>-</td>
                    </tr>
                    <tr>
                        <td>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;- HUBUNGAN</td>
                        <td>:</td>
                        <td>-</td>
                    </tr>
                    <tr>
                        <td>ASAL PASIEN</td>
                        <td>:</td>
                        <td> - &nbsp;&nbsp; DATANG SENDIRI</td>
                    </tr>
                    <tr>
                        <td></td>
                        <td></td>
                        <td> - &nbsp;&nbsp; DI ANTAR</td>
                    </tr>
                    <tr>
                        <td></td>
                        <td></td>
                        <td> - &nbsp;&nbsp; RUJUKAN</td>
                    </tr>
                </table>
                <br><br><br>
                <form action="<?= base_url('pendaftaran/simpanformpendaftaran/' . $this->uri->segment(3)); ?>" method="post">
                    <table width="100%">
                        <tr>
                            <td align="center"></td>
                            <td align="center">
                                Jakarta, <?= date('d F Y'); ?> <br>
                                Jam <?= date('H:i'); ?>
                                <br><br>
                            </td>
                        </tr>
                        <tr>
                            <td align="center">
                                Yang menjelaskan<br>
                                <img src="<?= base_url('images/uploadsign/pendaftaran/' . $ttd['ttd_yang_menjelaskan']); ?>.png" alt="">
                                <br>
                                <p>
                                    (<?= $ttd['yang_menjelaskan']; ?>)
                                </p>
                            </td>
                            <td align="center">
                                Pasien/Penanggung jawab pasien <br>
                                <img src="<?= base_url('images/uploadsign/pendaftaran/' . $ttd['ttd_pasien']); ?>.png" alt="">
                                <br>
                                <p>
                                    (<?= $ttd['pasien']; ?>)
                                </p>
                            </td>
                        </tr>
                    </table>
                    <script>
                        window.onload = function() {
                            window.print();
                            setTimeout(window.close, 500);
                        };
                    </script>