{% extends '@RxConnexion/Admin/content.html.twig' %}
{% block content %}
    <form method="POST" action="{{ path('referring_provider_schedule_form', {referring_provider_id : referring_provider_id, action: action, id: id}) }}">
        <div class="row max-width-initial">
            <div class="large-6 columns">
                <h5>Schedule information</h5>
                <p class="form-hint-text">Enter schedule information below</p>
                <div class="row">
                    <div class="large-3 large-text-right columns">
                        {{ form_label(form.health_facility_desc) }}
                    </div>
                    <div class="large-9 columns">
                        {{ form_widget(form.health_facility_desc) }}
                        {{ form_widget(form.health_facility) }}
                    </div>
                </div>
                <div class="row">
                    <div class="large-3 large-text-right columns">
                        {{ form_label(form.marketingStaff_fullName) }}
                    </div>
                    <div class="large-9 columns">
                        {{ form_widget(form.marketingStaff_fullName) }}
                        {{ form_widget(form.marketingStaff) }}
                    </div>
                </div>
                <div class="row">
                    <div class="large-3 large-text-right columns">
                        {{ form_label(form.note_type) }}
                    </div>
                    <div class="large-9 columns">
                        {{ form_widget(form.note_type) }}
                    </div>
                </div>
                <div class="row">
                    <div class="large-3 large-text-right columns">
                        {{ form_label(form.note) }}
                    </div>
                    <div class="large-9 columns">
                        {{ form_widget(form.note) }}
                    </div>
                </div>
            </div>
            <div class="large-6 columns" style="margin-top: 70px;">
                <div class="row">
                    <div class="large-3 large-text-right columns">
                        {{ form_label(form.marketingStaffScheduleStatus) }}
                    </div>
                    <div class="large-9 columns">
                        {{ form_widget(form.marketingStaffScheduleStatus) }}
                    </div>
                </div>
                <div class="row">
                    <div class="large-3 large-text-right columns">
                        {{ form_label(form.chartType_desc) }}
                    </div>
                    <div class="large-9 columns">
                        {{ form_widget(form.chartType_desc) }}
                        {{ form_widget(form.chartType) }}
                    </div>
                </div>
                <div class="row">
                    <div class="large-3 large-text-right columns">
                        {{ form_label(form.schedule_date) }}
                    </div>
                    <div class="large-9 columns">
                        {{ form_widget(form.schedule_date) }}
                    </div>
                </div>
                <div class="row">
                    <div class="xxlarge-6 xlarge-6 large-6 medium-6 small-12 columns">
                        <label class="required">Start Time</label>
                        <div class="row collapse">
                            <div class="xxlarge-3 xlarge-3 large-3 medium-3 small-3 columns">
                                {{ form_widget(form.start_time_hour) }}
                            </div>
                            <div class="xxlarge-1 xlarge-1 large-1 medium-1 small-1 columns text-center">:</div>
                            <div class="xxlarge-3 xlarge-3 large-3 medium-3 small-3 columns">
                                {{ form_widget(form.start_time_minute) }}
                            </div>
                            <div class="xxlarge-1 xlarge-1 large-1 medium-1 small-1 columns text-center">&nbsp;</div>
                            <div class="xxlarge-3 xlarge-3 large-3 medium-3 small-3 columns end">
                                {{ form_widget(form.start_time_period) }}
                            </div>
                        </div>
                    </div>
                    <div class="xxlarge-6 xlarge-6 large-6 medium-6 small-12 columns">
                        <label class="required">End Time</label>
                        <div class="row collapse">
                            <div class="xxlarge-3 xlarge-3 large-3 medium-3 small-3 columns">
                                {{ form_widget(form.end_time_hour) }}
                            </div>
                            <div class="xxlarge-1 xlarge-1 large-1 medium-1 small-1 columns text-center">:</div>
                            <div class="xxlarge-3 xlarge-3 large-3 medium-3 small-3 columns">
                                {{ form_widget(form.end_time_minute) }}
                            </div>
                            <div class="xxlarge-1 xlarge-1 large-1 medium-1 small-1 columns text-center">&nbsp;</div>
                            <div class="xxlarge-3 xlarge-3 large-3 medium-3 small-3 columns end">
                                {{ form_widget(form.end_time_period) }}
                            </div>
                        </div>
                    </div>
                </div>
            </div>
            {#<div class="large-12 columns">#}
                {#<h5>Fax details</h5>#}
                {#<p class="form-hint-text">Enter fax details below</p>#}
                {#<div class="row">#}
                    {#<div class="large-2 large-text-right columns">#}
                        {#{{ form_label(form.faxCoverSelection) }}#}
                    {#</div>#}
                    {#<div class="large-10 columns">#}
                        {#{{ form_widget(form.faxCoverSelection) }}#}
                    {#</div>#}
                {#</div>#}
                {#<div class="row">#}
                    {#<div class="large-2 large-text-right columns">#}
                        {#{{ form_label(form.faxBodySelection) }}#}
                    {#</div>#}
                    {#<div class="large-10 columns">#}
                        {#{{ form_widget(form.faxBodySelection) }}#}
                    {#</div>#}
                {#</div>#}
            {#</div>#}
            <div class="small-12 columns">
                <hr class="max-width-initial">
                <div class="button-container">
                    <button type="submit" class="button just-continue" name="action" value="{{ action }}"
                            data-message="Are you sure you want to save this information?"
                    >Save</button>
                    {% if action == 'u' and (userData.type == 'Super Admin' or 'Admin Referring Provider Schedule Delete' in userData.accesses) %}
                        <button type="submit" class="ask-continue button alert" name="action" value="d"
                                data-message="Are you sure you want to delete this record?"
                        >Delete</button>
                    {% endif %}
                    <a href="{{ path('referring_provider_detail', {referringProvider_id:referring_provider_id, tab:'ap'}) }}" class="button secondary">Back</a>
                </div>
            </div>
        </div>
        {{ form_widget(form.action) }}
        {{ form_widget(form.id) }}
        {{ form_widget(form.referringProvider) }}
        {{ form_widget(form._token) }}
    </form>
    {#{% if action != 'n' %}#}
    {#<form method="POST" action="{{ path('appointment_notice_form', {patient_id: patient_id, schedule_id: id}) }}">#}
        {#<div class="row max-width-initial">#}
            {#<hr class="max-width-initial">#}
            {#<div class="large-12 columns">#}
                {#<h5>Create new appointment notice</h5>#}
                {#<div class="row">#}
                    {#<div class="large-6 columns">#}
                        {#{{ form_label(form2.affiliate_type) }}#}
                        {#{{ form_widget(form2.affiliate_type) }}#}
                    {#</div>#}
                    {#<div class="large-6 columns">#}
                        {#<div id="affiliate-Referring-Provider" class="hide">#}
                            {#{{ form_label(form2.patient_referring_provider_desc) }}#}
                            {#{{ form_widget(form2.patient_referring_provider_desc) }}#}
                            {#{{ form_widget(form2.patient_referring_provider) }}#}
                        {#</div>#}
                        {#<div id="affiliate-Referring-HealthFacility" class="hide">#}
                            {#{{ form_label(form2.patient_referring_health_facility_desc) }}#}
                            {#{{ form_widget(form2.patient_referring_health_facility_desc) }}#}
                            {#{{ form_widget(form2.patient_referring_health_facility) }}#}
                        {#</div>#}
                        {#<div id="affiliate-Insurance" class="hide">#}
                            {#{{ form_label(form2.patient_insurance_desc) }}#}
                            {#{{ form_widget(form2.patient_insurance_desc) }}#}
                            {#{{ form_widget(form2.patient_insurance) }}#}
                        {#</div>#}
                    {#</div>#}
                {#</div>#}
            {#</div>#}
            {#<div class="large-12 columns">#}
                {#<h5 class="subheader">Appointment Notices</h5>#}
                {#<table class="display responsive" id="appointmentNoticeFax-datalist" width="100%">#}
                    {#<thead>#}
                    {#<tr>#}
                        {#<th>Date/Time</th>#}
                        {#<th>Schedule ID</th>#}
                        {#<th>Type</th>#}
                        {#<th>Name</th>#}
                        {#<th>Action</th>#}
                    {#</tr>#}
                    {#</thead>#}
                    {#<tbody></tbody>#}
                {#</table>#}
            {#</div>#}
            {#<div class="small-12 columns">#}
                {#<hr class="max-width-initial">#}
                {#<div class="button-container">#}
                    {#<button type="submit" class="button just-continue hide" id="create-new-appointment-notice-save" name="action" value="{{ action }}"#}
                            {#data-message="Are you sure you want to save this information?"#}
                    {#>Save</button>#}
                {#</div>#}
            {#</div>#}
        {#</div>#}
        {#{{ form_widget(form2.action) }}#}
        {#{{ form_widget(form2.id) }}#}
        {#{{ form_widget(form2.patient) }}#}
        {#{{ form_widget(form2.schedule) }}#}
        {#{{ form_widget(form2._token) }}#}
    {#</form>#}
    {#{% endif %}#}
    {% include '@RxConnexion/Admin/js.html.twig' %}
    <script>
        //<![CDATA[
        referring_provider_schedule_form.settings.medical_facility_autocomplete_url = '{{ path('health_facility_autocomplete') }}';
        referring_provider_schedule_form.settings.marketing_staff_autocomplete_url = '{{ path('marketing_staff_autocomplete') }}';
        referring_provider_schedule_form.settings.patient_referring_provider_autocompleteUrl = '{{ path('patient_referring_provider_autocomplete') }}';
        referring_provider_schedule_form.settings.patient_referring_health_facility_autocompleteUrl = '{{ path('patient_referring_health_facility_autocomplete') }}';
        referring_provider_schedule_form.settings.patient_insurance_autocompleteUrl = '{{ path('patient_insurance_autocomplete') }}';
        referring_provider_schedule_form.settings.chartType_autocompleteUrl = '{{ path('chart_type_autocomplete') }}';
        referring_provider_schedule_form.settings.referringProviderId = '{{ referring_provider_id }}';
        referring_provider_schedule_form.settings.scheduleId = '{{ id }}';
        {#patient_schedule_form.settings.appointmentNoticeFax_ajaxUrl= '{{ path('patient_appointment_notice_fax_ajax_list') }}';#}
        jQ(document).ready(function(){
            referring_provider_schedule_form.init();
        });
        //]]>
    </script>
{% endblock %}