{% set absUrl = app.request.getSchemeAndHttpHost() ~ app.request.baseUrl|replace({'/app_dev.php': ''}) %}
{% set userData = app.session.get('userData') %}
<!DOCTYPE html>
<html class="no-js" lang="en" dir="ltr">
<head>
	<meta charset="utf-8">
	<meta http-equiv="x-ua-compatible" content="ie=edge">
	<meta name="viewport" content="width=device-width, initial-scale=1.0">
	<title>DSRC Letter</title>
</head>
<body style="font-family:'Arial'; font-size:18px;">
<div style="width:768px; position: relative; padding:0px; margin: 0 auto; box-shadow:3px 1px 10px 1px;">
	{#<h3 style="text-align: center;  border:1px solid #6F71B3; margin-left: 60px; margin-right: 60px; box-sizing: border-box; margin-top:55px; padding-right: 40px;">FAX FORM</h3>#}
	<div style="margin-top:12px; height: 150px; width:100%;">
		<div style="width: 50%; height: 230px; float: left; box-sizing: border-box; padding-right: 5px;">

			{% set attn = '' %}
			{% if faxingOption.referringHealthFacility is not null or faxingOption.referringHealthFacility != '' %}
				{% set attn = faxingOption.referringHealthFacility.description %}
			{% elseif faxingOption.referringProvider is not null or faxingOption.referringProvider != '' %}
				{% set attn = 'Dr. '~faxingOption.referringProvider.fullName %}
			{% else %}
				{% set attn = faxingOption.insurance.description %}
			{% endif %}

			<p style="margin-bottom: 5px;">TO:</p>
			<div style="width: 100%; height: 100%; border:1px solid #6F71B3; box-sizing: border-box; padding:10px;">
				<table>
					<tr>
						<td style="width: 15%;">Attention</td>
						<td style="width: 2%;">:</td>
						<td style="width: 83%;">{{ attn }}</td>
					</tr>
					<tr>
						<td style="width: 15%;">RE</td>
						<td style="width: 2%;">:</td>
						<td style="width: 83%;">{{ faxingOption.patient.fullName|default('') }}</td>
					</tr>
					<tr>
						<td style="width: 15%;">Date</td>
						<td style="width: 2%;">:</td>
						<td style="width: 83%;">{{ faxingOption.createdAt|date('m/d/Y') }}</td>
					</tr>
					<tr>
						<td style="width: 15%;">Phone</td>
						<td style="width: 2%;">:</td>
						<td style="width: 83%;">{{ faxingOption.referringHealthFacility ? faxingOption.referringHealthFacility.phoneNo : ''  }}</td>
					</tr>
					<tr>
						<td style="width: 15%;">Fax</td>
						<td style="width: 2%;">:</td>
						<td style="width: 83%;">{{ faxingOption.faxNo|default('') }}</td>
					</tr>
				</table>
			</div>
		</div>
		<div style="width: 50%; height: 150px; float: right; box-sizing: border-box; padding-left: 5px;">
			<p style="margin-bottom: 5px;">FROM:</p>
			<div style="width: 100%; height: 100%; border:1px solid #6F71B3; box-sizing: border-box; padding:10px;">
				<table>
					<tr>
						<td style="width: 40%;">Name</td>
						<td style="width: 60%;">: {{ faxingOption.name != '' or faxingOption.name is not null ? faxingOption.name : userData.fullName }}</td>
					</tr>
					<tr>
						<td style="width: 40%;">Pages</td>
						{#<td style="width: 60%;">: {{ patientLetter.page != '' or patientLetter.page is not null ? patientLetter.page : '2' }}</td>#}
						<td style="width: 60%;">: {{ faxingOption.page|default('') }}</td>
					</tr>
					{#<tr>#}
						{#<td style="width: 40%;">CC</td>#}
						{#<td style="width: 60%;">: {{ patientLetter.carbonCopy != '' or patientLetter.carbonCopy is not null ? patientLetter.carbonCopy : '_______' }}</td>#}
						{#<td style="width: 60%;">: {{ patientLetter.getPatientLetterCcDescAsString }}</td>#}
					{#</tr>#}
				</table>
			</div>
		</div>
	</div>
	{% set faxCoverSelection = faxingOption.faxCoverSelection|split(',') %}
	<div style="width:49.5%; height: 70px; margin-top: 37px; box-sizing: border-box; padding:15px; border:1px solid #6F71B3; float: right">
		<div style="width: 100%; height: 100%;">
			<input type="checkbox" id="urgent" style="height: 18px; width:18px;" {{ 1 in faxCoverSelection ? 'checked' : '' }}><label style="font-size: 11px; margin-right:40px;"><strong>Urgent</strong></label>
			<input type="checkbox" id="urgent" style="height: 18px; width:18px;" {{ 2 in faxCoverSelection ? 'checked' : '' }}><label style="font-size: 11px; margin-right:40px;"><strong>For Review</strong></label>
			{#<input type="checkbox" id="urgent" style="height: 18px; width:18px;" {{ 3 in faxCoverSelection ? 'checked' : '' }}><label style="font-size: 18px; margin-right:40px;"><strong>Please Comment</strong></label>#}
			<input type="checkbox" id="urgent" style="height: 18px; width:18px;" {{ 4 in faxCoverSelection ? 'checked' : '' }}><label style="font-size: 11px; margin-right:40px;"><strong>Please Reply</strong></label>
		</div>
	</div>
	<div style="width: 100%; height: 525px; margin-top:11px; border: 1px solid #6F71B3; box-sizing: border-box; padding:20px; float: left;">
		{{ faxingOption.customBody|raw }}
	</div>
	<div style="width: 100%; height: auto; float: left;">
		<p style="font-size: 12px;">This Facsimile transmission contains information which is confidential and/or privileged. This information is intended for use only by the addressee indicated above. If you are not the intended recipient, please be advised that any disclosure, copying, distribution or use of the contents of this information is stricly prohibited, and that any misdirected or improperly received information must be returned to this company immediately. Your cooperation in phoning us of erroneous receipt is requested.</p>
	</div>
</div>
</body>
</html>