{% set userData = app.session.get('userData') %}
<form method="POST" id="form-patientCreateTicket">
    <h5>{{ page_title }}</h5>
    <div id="flash-messages-content-modal"></div>
    <div class="row max-width-initial">
        <div class="large-12 columns">
            <div class="row">
                <div class="large-12 columns">
                    <label>Patient ID</label>
                    <input type="text" name="form[id]" readonly value="{{ patient_id }}">
                </div>
                <div class="large-12 columns">
                    <label>User</label>
                    <input type="text" id="ticket-user-assignment-fullName">
                    <input type="hidden" name="form[accountUser]" id="ticket-user-assignment">
                </div>
                <div class="large-6 columns">
                    <label>Status</label>
                    <select name="form[status]">
                        <option value=""></option>
                        {% for ticketStatus in ticketStatuses  %}
                        <option value={{ ticketStatus.id }}>{{ ticketStatus.description }}</option>
                        {% endfor %}
                    </select>
                </div>
                <div class="large-6 columns">
                    <label>Severity</label>
                    <select name="form[severity]">
                        <option value=""></option>
                        {% for ticketSeverity in ticketSeverities  %}
                        <option value={{ ticketSeverity.id }}>{{ ticketSeverity.description }}</option>
                        {% endfor %}
                    </select>
                </div>
                <div class="large-12 columns">
                    <label>Note</label>
                    <textarea rows="5" name="form[note]"></textarea>
                </div>
            </div>
        </div>
    </div>
    <hr>
    <div class="row-max-width-initial">
        <div class="small-12 columns no-padding-right">
            <div class="button-container clearfix text-right">
                <a href="javascript:void(0)" class="button just-continue href-update-is-done-action float-right"
                   data-message="Are you sure you want to save this information?"
                   style="margin-left: 10px; margin-right: 0;"
                >Save</a>
                <a href="javascript:void(0)" class="button secondary" data-close style="margin-left: 10px; margin-right: 0;">Close</a>
            </div>
        </div>
    </div>
</form>
<script language="javascript">
    //<![CDATA[
    //]]>
</script>