	<!DOCTYPE html>
		<html class="no-js" lang="en" dir="ltr">
			<head>
				<meta charset="utf-8">
				<meta http-equiv="x-ua-compatible" content="ie=edge">
				<meta name="viewport" content="width=device-width, initial-scale=1.0">
				<title>DSRC Letter</title>
			</head>
			<body style="font-family:'Arial'; font-size:15px;">
				<div style="width:766px; height: 1056px; padding:50px; margin: 0 auto; box-shadow:3px 1px 10px 1px;">
					<img src="{{ app.request.getSchemeAndHttpHost() ~ '/bundles/rxconnexion/images/patientLetterLogo.jpg' }}" style="width: 40%;"/>
					<div style="width: 100%; height: auto; text-align:left;margin-top: 70px;">
						{% if patientLetter.patientReferringProvider %}
							{% set receiverFullName = patientLetter.patientReferringProvider.referringProvider.fullName %}
							{% set receiverPhone = patientLetter.patientReferringProvider.referringProvider.phoneNo is null ? patientLetter.patientReferringProvider.referringProvider.phoneNoTwo : patientLetter.patientReferringProvider.referringProvider.phoneNo %}
							{% set receiverFax = patientLetter.patientReferringProvider.referringProvider.faxNo is null ? patientLetter.patientReferringProvider.referringProvider.faxNoTwo : patientLetter.patientReferringProvider.referringProvider.faxNo %}
							<p style="margin:2px">{{ receiverFullName }} </p>
							<p style="margin:2px">Mental Institution</p>
							<p style="margin:2px">{{ patientLetter.patientReferringProvider.referringProvider.address }}</p>
						{% endif %}
						{% if patientLetter.patientReferringHealthFacility %}
							{% set receiverFullName = patientLetter.patientReferringHealthFacility.referringHealthFacility.description %}
							{% set receiverPhone = patientLetter.patientReferringHealthFacility.referringHealthFacility.phoneNo is null ? patientLetter.patientReferringHealthFacility.referringHealthFacility.phoneNoTwo : patientLetter.patientReferringHealthFacility.referringHealthFacility.phoneNo %}
							{% set receiverFax = patientLetter.patientReferringHealthFacility.referringHealthFacility.faxNo is null ? patientLetter.patientReferringHealthFacility.referringHealthFacility.faxNoTwo : patientLetter.patientReferringHealthFacility.referringHealthFacility.faxNo %}
							<p style="margin:2px">{{ receiverFullName }} </p>
							<p style="margin:2px">Mental Institution</p>
							<p style="margin:2px">{{ patientLetter.patientReferringHealthFacility.referringHealthFacility.address }}</p>
						{% endif %}
						{% if patientLetter.patientInsurance %}
							{% set receiverFullName = patientLetter.patientInsurance.insurance.description %}
							{% set receiverPhone = patientLetter.patientInsurance.insurance.phoneNo is null ? patientLetter.patientInsurance.insurance.phoneNoTwo : patientLetter.patientInsurance.insurance.phoneNo %}
							{% set receiverFax = patientLetter.patientInsurance.insurance.faxNo is null ? patientLetter.patientInsurance.insurance.faxNoTwo : patientLetter.patientInsurance.insurance.faxNo %}
							<p style="margin:2px">{{ receiverFullName }} </p>
							<p style="margin:2px">Mental Institution</p>
							{#<p style="margin:2px">{{ patientLetter.patientInsurance.insurance.address }}</p>#}
						{% endif %}
					</div>
					<div style="width: 100%; height: auto; text-align:left;margin-top: 30px;">
						<p style="margin:2px">{{ 'now'|date('F j, Y') }}</p>
					</div>
					<div style="width: 100%; height: auto; text-align:left;margin-top: 30px;">
						{% set patientFullName = patientLetter.patient.fullName %}
						{% set patientFirstName = patientLetter.patient.firstName %}
						{% set patientLastName = patientLetter.patient.lastName %}
						<p style="margin:2px">Patient Name: {{ patientLastName ~','~ patientLastName }}</p>
						<p style="margin:2px">Date of Birth: {{ patientLetter.patient.birthdate|date('F j, Y') }}</p>
						<p style="margin:2px">PHN: 000000</p>
					</div>
					<div style="width: 100%; height: auto; text-align:left;margin-top: 30px;">
						<p style="margin:2px">Dear {{ receiverFullName }},</p>
					</div>
					<div style="width: 100%; height: auto; text-align:left;margin-top: 20px;">
						<p style="margin:2px">Thank you for referring your patient {{ patientFullName }} to Dynamic Sleep & Respiratory Care. {{ patientFullName }} had a Home Sleep Apnea Test (HSAT) and based on the interpretation provided by our Sleep Physician Dr. Salem Alewan, {{ patientFullName }}'s study indicated Obstructive Sleep Apnea (AHI=2 and RDI=4). </p>
					</div>					
					<div style="width: 100%; height: auto; text-align:left;margin-top: 20px;">
						<p style="margin:2px">We advised {{ patientFullName }} of his results and he elected not to go forward with a CPAP Evaluation at this time because he was concerned that he would not be able to afford the treatment. We offered an interest free payment plan, however {{ patientFullName }} was not interested and decided to delay treatment.</p>
					</div>	
					<div style="width: 100%; height: auto; text-align:left;margin-top: 20px;">
						<p style="margin:2px">We spent time discussing the implications of untreated OSA and suggested that {{ patientFullName }} consider alternative treatments including a mandibular advancement splint or possible ENT consult if he is unable to tolerate CPAP. {{ patientFullName }} was also encouraged to follow up with you in the near future. </p>
					</div>				
					<div style="width: 100%; height: auto; text-align:left;margin-top: 20px;">
						<p style="margin:2px">Should you have any questions or if we could be of further assistance, please do not hesitate to contact us.</p>
					</div>
					<div style="width: 100%; height: auto; text-align:left;margin-top: 20px;">
						<p style="margin:2px">Thank you for your continued support.</p>
					</div>
					<div style="width: 100%; height: auto; text-align:left;margin-top: 20px;">
						<p style="margin:2px">Sincerely,</p>
					</div>
					<div style="width: 100%; height: auto; text-align:left;margin-top: 50px;">
						<p style="margin:2px">{{ userData.fullName }}</p>
						<p style="margin:2px">Dynamic Sleep & Respiratory Care</p>
					</div>
				</div>
				<!------ 2ND PAGE --------->
				<div style="width:766px; height: 1056px; padding:50px; margin: 0 auto; margin-top: 20px; box-shadow:3px 1px 10px 1px;">
					<img src="{{ app.request.getSchemeAndHttpHost() ~ '/bundles/rxconnexion/images/patientLetterLogo.jpg' }}" style="width: 40%;"/>
					<div style="width: 100%; height: auto; text-align:left;margin-top: 70px;">
						<h2 style="text-align: center;">Fax Cover Sheet</h2>
						<div style="margin-top:60px; height: 150px; width:100%; padding: 5px;">
							<div style="width: 50%; height: 150px; float: left; box-sizing: border-box; padding: 10px;">
								<p>TO:</p>
								<div style="width: 100%; /**height: 100%**/; border:1px solid #000; box-sizing: border-box; padding:10px;">
									<table>
										<tr>
											<td style="width: 40%;">ATTN</td>
											<td>: {{ receiverFullName }}</td>
										</tr>
										<tr>
											<td style="width: 40%;">RE</td>
											<td>: {{ patientFullName }}</td>
										</tr>
										<tr>
											<td style="width: 40%;">Date</td>
											<td>: {{ 'now'|date('F j, Y') }}</td>
										</tr>
										<tr>
											<td style="width: 40%;">Phone</td>
											<td>: {{ receiverPhone }}</td>
										</tr>
										<tr>
											<td style="width: 40%;">Fax</td>
											<td>: {{ receiverFax }}</td>
										</tr>
									</table>
								</div>
							</div>
							<div style="width: 50%; height: 150px; float: right; box-sizing: border-box; padding: 10px;">
								<p>FROM:</p>
								<div style="width: 100%; height: 100%; border:1px solid #000; box-sizing: border-box; padding:10px;">
									<table>
										<tr>
											<td style="width: 60%;">Name</td>
											<td>: {{ userData.fullName }}</td>
										</tr>
										<tr>
											<td style="width: 60%;">No. of Pages (inc. cover)</td>
											<td>: 2</td>
										</tr>
										<tr>
											<td style="width: 60%;">CC</td>
											<td>: Mr. Tom Smith</td>
										</tr>
									</table>
								</div>
							</div>
						</div>
						<div style="width:100%; height: 70px; margin-top: 80px; box-sizing: border-box; padding:20px; border:1px solid #000;">
							<div style="width: 100%; height: 100%;">
								<input type="checkbox" id="urgent" style="height: 18px; width:18px;"><label style="font-size: 18px; margin-right:40px;"><strong>Urgent</strong></label>
								<input type="checkbox" id="urgent" style="height: 18px; width:18px;"><label style="font-size: 18px; margin-right:40px;"><strong>For Review</strong></label>
								<input type="checkbox" id="urgent" style="height: 18px; width:18px;"><label style="font-size: 18px; margin-right:40px;"><strong>Please Comment</strong></label>
								<input type="checkbox" id="urgent" style="height: 18px; width:18px;"><label style="font-size: 18px; margin-right:40px;"><strong>Please Reply</strong></label>
							</div>
						</div>
						<div style="width: 100%; height: auto; margin-top:25px; border: 1px solid #000; box-sizing: border-box; padding:20px;">
							<p><strong>Notes:</strong></p>
							<p style="margin:0;">Good day {{ receiverFullName }}</p>
							<p>Thank you for your referral.</p>
							<p>Please find attached letter regarding your patient {{ patientFullName }}</p>
							<p>Kind regards,</p>
							<br>
							<p style="margin:0;">{{ userData.fullName }}</p>
							<p style="margin:0;">Dynamic Sleep Respiratory Care</p>
						</div>
						<p style="font-size: 10px;">"This Facsimile transmission contains information which is confidential and/or privileged. This information is intended for use only by the addressee indicated above. If you are not the intended recipient, please be advised that any disclosure, copying, distribution or use of the contents of this information is stricly prohibited, and that any misdirected or improperly received information must be returned to this company immediately. Your cooperation in phoning us of erroneous receipt is requested."</p>
					</div>
				</div>
			</body>
		</html>