{% extends '@RxConnexion/Admin/content.html.twig' %}
{% block content %}
    <style>
        #pdf {
            display: none;
        }
        #excel {
            display: none;
        }
    </style>
    <div class="row max-width-initial">
        <div class="small-12 columns">
            <div class="content-container">
                <div class="content-container-content">
                    <div class="row max-width-initial">
                        <div class="large-12 columns">
                            <div class="row max-width-initial">
                                <div class="large-6 medium-6 small-12 columns">
                                    <label>Status</label>
                                    <select name="" id="status">
                                        <option value="active">Active</option>
                                        <option value="inactive">Inactive</option>
                                    </select>
                                </div>
                                <div class="large-6 medium-6 small-12 columns">
                                    <label>Referring Affiliate</label>
                                    <input type="text" id="form-referring-health-facility" />
                                    <input type="hidden" id="form-referring-health-facility-id" />
                                </div>
                                <div class="large-6 medium-6 small-12 columns">
                                    <label>City</label>
                                    <input type="text" id="form-city-desc" />
                                    <input type="hidden" id="form-city-id" />
                                </div>
                                {#<div class="large-6 medium-6 small-12 columns">#}
                                    {#<label for="no_contact_no">No Contact #</label>#}
                                    {#<input type="checkbox" id="no_contact_no" />#}
                                {#</div>#}
                                {#<div class="large-6 medium-6 small-12 columns">#}
                                    {#<label for="no_mobile_no">No Mobile #</label>#}
                                    {#<input type="checkbox" id="no_mobile_no" />#}
                                {#</div>#}
                                {#<div class="large-6 medium-6 small-12 columns">#}
                                    {#<label for="no_email">No Email</label>#}
                                    {#<input type="checkbox" id="no_email" />#}
                                {#</div>#}
                            </div>
                        </div>
                    </div>
                    {%
                        include '@RxConnexion/Report/buttons.html.twig'
                        with {
                        'preview_url': 'main/report/count_patient_referring_provider/preview',
                        'export_to_pdf_url': 'main/report/count_patient_referring_provider/export_to_pdf',
                        'export_to_excel_url': 'main/report/count_patient_referring_provider/export_to_excel',
                        'paramsIds': 'form-referring-health-facility-id|status|form-city-id'
                    }
                    %}
                </div>
            </div>
        </div>
    </div>
    {% include '@RxConnexion/Admin/js.html.twig' %}
    <script language="javascript">
        //<![CDATA[
        patientReferringHealthFacilityCount.settings.referringHealthFacility_autocompleteUrl = '{{ path('referring_health_facility_autocomplete') }}';
        patientReferringHealthFacilityCount.settings.city_autocompleteUrl = '{{ path('city_autocomplete') }}';
        jQ(document).ready(function(){
            report.init('{{ app.environment }}');
            patientReferringHealthFacilityCount.init();
        });
        //]]>
    </script>
{% endblock %}