{% set userData = app.session.get('userData') %}
<form method="POST" id="form-faxTran">
    <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.remote_id) }}
                    {{ form_widget(form.remote_id) }}
                </div>
                <div class="large-6 columns">
                    {{ form_label(form.fax_date) }}
                    {{ form_widget(form.fax_date) }}
                </div>
                <div class="large-12 columns">
                    {{ form_label(form.fax_category) }}
                    {{ form_widget(form.fax_category) }}
                </div>
                <div class="large-12 columns">
                    {{ form_label(form.health_facility_desc) }}
                    {{ form_widget(form.health_facility_desc) }}
                    {{ form_widget(form.health_facility) }}
                </div>
                <div class="large-12 columns">
                    {{ form_label(form.account_user_name) }}
                    {{ form_widget(form.account_user_name) }}
                    {{ form_widget(form.account_user) }}
                </div>
                <div class="large-12 columns">
                    {{ form_label(form.fax_status) }}
                    {{ form_widget(form.fax_status) }}
                </div>
                <div class="large-12 columns">
                    <div class="row">
                        <div class="large-6 columns">
                            {{ form_widget(form.is_duplicate) }}
                            {{ form_label(form.is_duplicate) }}
                        </div>
                        <div class="large-6 columns">
                            {{ form_widget(form.is_unable_to_process) }}
                            {{ form_label(form.is_unable_to_process) }}
                        </div>
                    </div>
                </div>
                <div class="large-12 columns">
                    {{ form_widget(form.patient) }}
                    {{ form_widget(form.is_existing) }}
                    {{ form_label(form.is_existing) }}
                    {{ form_widget(form.patient_name) }}
                </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-faxTran-action float-right" data-axn="{{ action }}"
                   data-message="Are you sure you want to save this information?"
                   style="margin-left: 10px; margin-right: 0;"
                >Save</a>
                {#{% endif %}#}
                {#{% if action == 'u' and (userData.type == 'Super Admin' or 'Admin Fax Delete' in userData.accesses) %}#}
                    {#<a href="javascript:void(0)" class="ask-continue button alert href-faxTran-action float-right" data-axn="d"#}
                       {#data-message="Are you sure you want to delete this record?"#}
                       {#style="margin-left: 10px; margin-right: 0;"#}
                    {#>Delete</a>#}
                {#{% endif %}#}
                <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.receive_status) }}
    {{ form_widget(form.size) }}
    {{ form_widget(form.fax_id) }}
    {{ form_widget(form.pages) }}
    {{ form_widget(form.file_name) }}
    {{ form_widget(form._token) }}
</form>