{% 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>Referral Date From</label>
                                    <input type="text" class="date" id="date_from" />
                                </div>
                                <div class="large-6 medium-6 small-12 columns">
                                    <label>Referral Date To</label>
                                    <input type="text" class="date" id="date_to" />
                                </div>
                            </div>
                            <div class="row max-width-initial">
                                <div class="large-6 medium-6 small-12 columns">
                                    <label>Receive Date From</label>
                                    <input type="text" class="date" id="receive_date_form" value="{{ 'now'|date('m/01/Y') }}" />
                                </div>
                                <div class="large-6 medium-6 small-12 columns">
                                    <label>Receive Date To</label>
                                    <input type="text" class="date" id="receive_date_to" value="{{ 'now'|date('m/d/Y') }}" />
                                </div>
                            </div>
                            <div class="row max-width-initial">
                                <div class="large-6 medium-6 small-12 columns">
                                    <label>Company</label>
                                    <select class="js-multiple-company" name="" id="companies" multiple="multiple" style="">
                                        {% for companies in company %}
                                            <option value="{{ companies.id }}">{{ companies.description }}</option>
                                        {% endfor %}
                                    </select>
                                    <input type="hidden" id="form-company-id" />
                                </div>
                                <div class="large-6 medium-6 small-12 columns">
                                    <label>Branch</label>
                                    <select class="js-multiple-branch" name="" id="branches" multiple="multiple" style="">
                                        {% for branches in branch %}
                                            <option value="{{ branches.id }}">{{ branches.description }}</option>
                                        {% endfor %}
                                    </select>
                                    <input type="hidden" id="form-branch-id" />
                                </div>
                            </div>
                            <div class="row max-width-initial">
                                <div class="large-6 medium-6 small-12 columns">
                                    <label>Referring Affiliate</label>
                                    <select class="js-multiple-referring-health-facility" name="" id="referringHealthFacilities" multiple="multiple" style="">
                                        {% for referringHealthFacilities in referringHealthFacility %}
                                            <option value="{{ referringHealthFacilities.id }}">{{ referringHealthFacilities.description }}</option>
                                        {% endfor %}
                                    </select>
                                    <input type="hidden" id="form-referring-health-facility-id" />
                                </div>
                                <div class="large-6 medium-6 small-12 columns">
                                    <label>Referring Physician</label>
                                    <select class="js-multiple-referring-provider" name="" id="referringProviders" multiple="multiple" style="">
                                        {% for referringProviders in referringProvider %}
                                            <option value="{{ referringProviders.id }}">{{ referringProviders.full_name }}</option>
                                        {% endfor %}
                                    </select>
                                    <input type="hidden" id="form-referring-provider-id" />
                                </div>
                            </div>
                            <div class="row max-width-initial">
                                <div class="large-6 medium-6 small-12 columns">
                                    <label>Services</label>
                                    <select class="js-multiple-service" name="" id="services" multiple="multiple" style="">
                                        {% for service in services %}
                                            <option value="{{ service.id }}">{{ service.description }}</option>
                                        {% endfor %}
                                    </select>
                                    <input type="hidden" id="form-service-id" />
                                </div>
                                <div class="large-6 medium-6 small-12 columns">
                                    <label>Primary Clinician</label>
                                    <select class="js-multiple-primary-provider" name="" id="primaryProviders" multiple="multiple" style="">
                                        {% for provider in providers %}
                                            <option value="{{ provider.id }}">{{ provider.providerName }}</option>
                                        {% endfor %}
                                    </select>
                                    <input type="hidden" id="form-primary-provider-id" />
                                </div>
                            </div>
                            <div class="row max-width-initial">
                                <div class="large-6 medium-6 small-12 columns">
                                    <label>File Type</label>
                                    <select class="js-multiple-file-type" name="" id="fileTypes" multiple="multiple" style="">
                                        {% for fileType in fileTypes %}
                                            <option value="{{ fileType.id }}">{{ fileType.description }}</option>
                                        {% endfor %}
                                    </select>
                                    <input type="hidden" id="form-file-type-id" />
                                </div>
                                <div class="large-6 medium-6 small-12 columns">
                                </div>
                            </div>
                            <div class="row max-width-initial">
                                <div class="large-6 medium-6 small-12 columns" style="margin-top: 20px;">
                                    <input type="checkbox" id="is_due">
                                    <label for="is_due">Due</label>
                                    <input type="hidden" id="form-is-due" />
                                </div>
                            </div>
                            <input type="hidden" id="chartType" />
                            <input type="hidden" id="chartStatus" />
                        </div>
                    </div>
                    {%
                        include '@RxConnexion/Report/buttons.html.twig'
                        with {
                        'preview_url': 'main/report/patient_cycle/preview',
                        'export_to_pdf_url': '',
                        'export_to_excel_url': '',
                        'paramsIds': 'date_from|date_to|receive_date_form|receive_date_to|form-company-id|form-branch-id|form-referring-health-facility-id|form-referring-provider-id|chartType|chartStatus|form-service-id|form-primary-provider-id|form-file-type-id|form-is-due'
                    }
                    %}
                </div>
            </div>
        </div>
    </div>
    {% include '@RxConnexion/Admin/js.html.twig' %}
    <script language="javascript">
        //<![CDATA[
        jQ(document).ready(function(){
            jQ('.js-multiple-company, .js-multiple-branch, .js-multiple-referring-health-facility, .js-multiple-referring-provider, .js-multiple-service, .js-multiple-primary-provider, .js-multiple-file-type').select2();
            report.init('{{ app.environment }}');
            patientCycle.init();
        });
        //]]>
    </script>
{% endblock %}