{#{% set userData = app.session.get('userData') %}#}
<form method="POST" id="form-patientAppointmentNoticeFax" action="{{ path('appointment_notice_form', {patient_id: patient_id, schedule_id: schedule_id}) }}">
    <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-6 columns">
                    {{ form_label(form.affiliate_type) }}
                    {{ form_widget(form.affiliate_type) }}
                </div>
                <div class="large-6 columns">
                    <div id="affiliate-Referring-Provider" class="hide">
                        {{ form_label(form.patient_referring_provider_desc) }}
                        {{ form_widget(form.patient_referring_provider_desc) }}
                        {{ form_widget(form.patient_referring_provider) }}
                    </div>
                    <div id="affiliate-Referring-HealthFacility" class="hide">
                        {{ form_label(form.patient_referring_health_facility_desc) }}
                        {{ form_widget(form.patient_referring_health_facility_desc) }}
                        {{ form_widget(form.patient_referring_health_facility) }}
                    </div>
                    <div id="affiliate-Insurance" class="hide">
                        {{ form_label(form.patient_insurance_desc) }}
                        {{ form_widget(form.patient_insurance_desc) }}
                        {{ form_widget(form.patient_insurance) }}
                    </div>
                </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">
                {#{% if action == 'n' and (userData.type == 'Super Admin' or 'Admin Patient Letter New' in userData.accesses) %}#}
                {#<a href="{{ sendFax }}" class="button just-continue float-right"#}
                <button type="submit" class="button just-continue float-right"
                   data-message="Are you sure you want to save this information?"
                   style="margin-left: 10px; margin-right: 0;"
                >Save</button>
                <a href="javascript:void(0)" class="button secondary" data-close style="margin-left: 10px; margin-right: 0;">Close</a>
            </div>
        </div>
    </div>
    {{ form_widget(form.action) }}
    {{ form_widget(form.id) }}
    {{ form_widget(form.patient) }}
    {{ form_widget(form.schedule) }}
    {{ form_widget(form._token) }}
</form>
<script language="javascript">
    //<![CDATA[
    //]]>
</script>