{AJAXCONTENT}

<table cellspacing="0" cellpadding="0" width="95%" border="0"  height="380px">
	<tr>
		<td valign="top"  style="width:100%" align="center">	<br/>
			 <table   cellspacing="0" cellpadding="5" width="100%" border="0" >	
				<tr>
					<td valign="top"  style="width:30%" align="center">	<br/>
						 <table   cellspacing="2" cellpadding="10" width="50%" border="0" style="border:4px double silver;-moz-border-radius:10px;-webkit-border-radius:10px;border-radius:10px">	
							<tr bgcolor="#eeeeee">
								<td align="center" colspan="2"><B>Hospital Tariff (Rate card)</B></td>
							</tr>

							<tr>
								<td align="left">Tariff Code: </td>
								<td align="left"><input name="tariffcode" type="text" class="textx" value="{TARIFFCODE}" style="width:150px"></td>
							</tr>

							<tr>
								<td align="left">Service: </td>
								<td align="left"><input name="service" type="text" class="textx" value="{SERVICE}" style="width:150px"></td>
							</tr>

							<tr>
								<td align="left">Department: </td>
								<td align="left"><select type="text" class="textx" name="department" value="{DEPARTMENT}" style="width:150px">{OPTDEPT}</select></td>
							</tr>

							<tr>
								<td align="left">Amount: </td>
								<td align="left"><img src="{SKINS}images/rupee.jpeg" border="0" height="15px" width="15px"> &nbsp;<input name="amount" type="text" class="textx" value="{AMOUNT}" style="width:130px"></td>
							</tr>
							
							<tr><td colspan="2"></td></tr>
							
							<tr>
								<td align="center" colspan="2"><input name="submit" type="button" class="sleft" value="Submit" onclick="return formCheck3(theform);"></td>
							</tr>
						</table>
					</td>
				</tr>
			</table>
		<td>
	</tr>
</table><br>

<input type="hidden" name="appdate" value="{APPDATE}">
<input type="hidden" name="p_id" value="{P_ID}">
<input type="hidden" name="w_id" value="{W_ID}">