{% 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; margin-top:35px; padding-right: 40px;">Fax Cover</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 #479085; 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 #479085; 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.pfaultge != '' 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: 51px; box-sizing: border-box; padding:15px; border:1px solid #479085; 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: 600px; margin-top:11px; border: 1px solid #479085; box-sizing: border-box; padding:20px; float: left;">
		{{ faxingOption.customBody|raw }}
	</div>
</div>
</body>
</html>