{% extends 'MainBundle:Master:template.html.twig' %}
{% block scripts %}

    {#<link rel="stylesheet" href="{{ asset('bundles/receive/css/receive.css') }}"/> #}
    {# selectpicker #}
    <link rel="stylesheet" href="{{ asset('bundles/indicator/css/bootstrap-select.css') }}"/>
    {#Bootstrap#}
    <link rel="stylesheet" href="{{ asset('bundles/utilities/bootstrap-3.3.7/css/bootstrap.min.css') }}"/>
    {#<link rel="stylesheet" href="{{ asset('bundles/shedule/'~ hrk_skin ~'/navs.css') }}"/>#}
    {#<link rel="stylesheet" href="{{ asset('bundles/shedule/'~ hrk_skin ~'/dataTableCustom.css') }}"/>#}
    <script type="text/javascript" src="{{ asset('bundles/shedule/js/receive_Appointment.js') }}"></script>
    <script type="text/javascript" src="{{ asset('bundles/shedule/bootstrap/jquery.bootstrap.wizard.js') }}"></script>
    <script type="text/javascript" src="{{ asset('bundles/shedule/bootstrap/js/bootstrap.js') }}"></script>
    <script type="text/javascript" src="{{ asset('bundles/indicator/js/bootstrap-select.js') }}"></script>
    <script type="text/javascript" src="{{ asset('bundles/shedule/js/blockUI.js') }}"></script>

    <script type="text/javascript" src="{{ asset('bundles/shedule/js/receive_Appointment_Scheduled.js') }}"></script>
    <script type="text/javascript" src="{{ asset('bundles/shedule/datatable/js/jquery.dataTables.min.js') }}"></script>
    <script type="text/javascript" src="{{ asset('bundles/shedule/datatable/js/dataTables.tableTools.js') }}"></script>
    <script type="text/javascript" src="{{ asset('bundles/shedule/datatable/js/dataTables.responsive.js') }}"></script>
    <script type="text/javascript" src="{{ asset('bundles/shedule/datatable/js/dataTables.bootstrap.js') }}"></script>
    <link rel="stylesheet" href="{{ asset('bundles/shedule/datatable/css/dataTables.bootstrap.css') }}"/>
    <link rel="stylesheet" href="{{ asset('bundles/shedule/datatable/css/dataTables.responsive.css') }}"/>
    <link rel="stylesheet" href="{{ asset('bundles/shedule/datatable/css/dataTables.tableTools.css') }}"/>
    <link rel="stylesheet" href="{{ asset('bundles/shedule/css/bootstrap-datetimepicker.min.css') }}"/>
    <script type="text/javascript" src="{{ asset('bundles/adesignscalendar/js/fullcalendar/moment.min.js') }}"></script>
    <script type="text/javascript" src="{{ asset('bundles/shedule/js/bootstrap-datetimepicker.min.js') }}"></script>
    <script src="{{ asset('bundles/fosjsrouting/js/router.js') }}"></script>
    <script src="{{ path('fos_js_routing_js', { callback: 'fos.Router.setData' }) }}"></script>
    <script>
        var cita6meses = "{{ 'messages.cita6meses'|trans([], 'LocalizationBundle') }}";
        var asignacion_citas = false;
        var id_cliente = '{{ id_cliente }}';
        {#var SrcGif = '{{ asset('bundles/utilities/images/anim_gif.gif') }}';        #}
        var SrcAlert = '{{ asset('bundles/utilities/images/alert.png') }}';
        var patientSelected = '0';
        var selectScheduleAppointment = '0';
        var selectSpace = '0';
        var URLfilterCie10 = '{{ path('filterCie10') }}';
        var filtroCie10 = '{{ 'messages.filtroCie10'|trans([], 'LocalizationBundle') }}';
        {#var select = '{{ 'button.select'|trans([], 'LocalizationBundle') }}';#}
        {#var UrlConsultarModalidadesConvenio = '{{ path('hiruko_consultar_modalidades_convenios') }}';#}
        var UrlDataEstudiosContratos = '{{ path('estudiosContratos') }}';
        var urlCopagosCuotaModeradora = '{{ path('CopagosCuotaModeradora') }}';
        var urlOrdenServicio = '{{ path('hiruko_factura_orden_servicio', {'cit':'cit'}) }}';
        var urlFactura = '{{ path('hiruko_factura', {'cit':'cit'}) }}';
        var urlSticker = '{{ path('PrintSticker76x60', {'appCode':'appCode'}) }}';
        var sticker = '{{ sticker }}';
        var urlRecibodePago = '{{ path('hiruko_factura_recibo_pago', {'cit':'cit'}) }}';
        var urlFacturaReciboCaja = '{{ path('hiruko_factura_recibos_caja', {'cit':'cit'}) }}';
        var urlContratosFacturacion = '{{ path('DefinicionContratosFacturacion') }}';
        var urlConsultaValores = '{{ path('ValoresEstudios') }}';
        {#var urlConsultaValoresContratos = '{{ path('ValoresContratos') }}';#}
        var urlConsultaValoresContratosC = '{{ path('ValoresContratosC') }}';
        {#var urlValidarResolucion = '{{ path("hiruko_validar_resolucion") }}';#}
        {#var urlConsultaConvenios = '{{ path('ConveniosLista') }}';#}
        var urlValidarSolicitudHIS = '{{ path("validar_solicitud_his") }}';
        var his_integration = '{{ his_integration }}';
        var id_cliente = '{{ id_cliente }}';
        var UrlNew = '{{ path("receive_appointment") }}';
        var urlSaveDataAppointmentReceive = '{{ path("receive_ScheduledAppointment_SaveDataAppointmentReceive") }}';
        var urlSendFile = '{{ path("receive_ScheduledAppointment_SendFileReceiveAppointment") }}';
        var urlFindConsentStudies = '{{ path('receive_FindConsentStudies', {'code':'code'}) }}';
        var urlValidateAppointment = '{{ path('receive_ValidateAppointmentAction') }}';
        var hijoDe = '{{ 'assistive.hijo_de'|trans([], 'LocalizationBundle') }}';
        {#var pleaseWait = '{{ 'messages.pleaseWait'|trans([], 'LocalizationBundle') }}';#}
        var errorAjax = '{{ 'messages.ajax.errorProcess'|trans([], 'LocalizationBundle') }}';
        var seguro = '{{ 'messages.seguro'|trans([], 'LocalizationBundle') }}';
        var aceptar = '{{ 'button.acept'|trans([], 'LocalizationBundle') }}';
        var cancelar = '{{ 'button.cancel'|trans([], 'LocalizationBundle') }}';
        var receiptOk = '{{ 'labels.appointment.receiptOk'|trans([], 'LocalizationBundle') }}';
        var noOrden = '{{ 'messages.noOrden'|trans([], 'LocalizationBundle') }}';
        var codigoAut_contrato = '{{ 'labels.appointment.codigoAut_contrato'|trans([], 'LocalizationBundle') }}';
        var facturacion= '{{ facturacion }}';
        {#var factura_cafam= '{{ factura_cafam }}';#}
        var factura_convenios = '{{ factura_convenio }}';
        var closer = "{{ asset('bundles/utilities/images/cerrar.png') }}";


        //    ***************************
        var search = "{{ 'labels.dataTable.search'|trans([], 'LocalizationBundle') }}";
        var lengthMenu = "{{ 'labels.dataTable.lengthMenu'|trans([], 'LocalizationBundle') }}";
        var info = "{{ 'labels.dataTable.info'|trans([], 'LocalizationBundle') }}";
        var infoFiltered = "{{ 'labels.dataTable.infoFiltered'|trans([], 'LocalizationBundle') }}";
        var InfoEmpty = "{{ 'labels.dataTable.InfoEmpty'|trans([], 'LocalizationBundle') }}";
        var loadingRecords = "{{ 'labels.dataTable.loadingRecords'|trans([], 'LocalizationBundle') }}";
        var zeroRecords = "{{ 'labels.dataTable.zeroRecords'|trans([], 'LocalizationBundle') }}";
        var emptyTable = "{{ 'labels.dataTable.emptyTable'|trans([], 'LocalizationBundle') }}";
        var first = "{{ 'labels.dataTable.paginate.first'|trans([], 'LocalizationBundle') }}";
        var previous = "{{ 'labels.dataTable.paginate.previous'|trans([], 'LocalizationBundle') }}";
        var next = "{{ 'labels.dataTable.paginate.next'|trans([], 'LocalizationBundle') }}";
        var last = "{{ 'labels.dataTable.paginate.last'|trans([], 'LocalizationBundle') }}";
        var findAllPatient = '{{ path('FindAllPatient') }}';
        var UrlDataScheduleAppointment = '{{ path("receive_ScheduledAppointment_FindDataScheduledAppointment") }}';
        var urlValidarResolucion = '{{ path("hiruko_validar_resolucion") }}';
        var urlConsultaResolucion = '{{ path("contratos_resolucion_valores") }}';
        var UrlScheduleLogs = '{{ path("receive_ScheduledAppointment_Logs") }}';
        var years = '{{ 'labels.date.years'|trans([], 'LocalizationBundle') }}';
        var months = '{{ 'labels.date.months'|trans([], 'LocalizationBundle') }}';
        var year = '{{ 'labels.date.years'|trans([], 'LocalizationBundle') }}';
        var month = '{{ 'labels.date.month'|trans([], 'LocalizationBundle') }}';
        var day = '{{ 'labels.date.day'|trans([], 'LocalizationBundle') }}';
        var days = '{{ 'labels.date.day'|trans([], 'LocalizationBundle') }}';
        var select = '{{ 'button.select'|trans([], 'LocalizationBundle') }}';
        var study = '{{ 'labels.study.singular'|trans([], 'LocalizationBundle') }}';
        var room = '{{ 'labels.room'|trans([], 'LocalizationBundle') }}';
        var modality = '{{ 'modalities.modality'|trans([], 'LocalizationBundle') }}';
        var ok = '{{ 'button.acept'|trans([], 'LocalizationBundle') }}';
        var cancel = '{{ 'button.cancel'|trans([], 'LocalizationBundle') }}';
        var ClinicalOrder = '{{ ClinicalOrder }}';
        var folio_consecutive = '{{ folio_consecutive }}';
        var consecutive = '{{ consecutive }}';
        var convenioL = '{{ 'labels.convenio'|trans([], 'LocalizationBundle') }}';
        var origin = '{{ 'labels.origin'|trans([], 'LocalizationBundle') }}';
        var assignMed = '{{ 'labels.medicoAsignado'|trans([], 'LocalizationBundle') }}';
        var citaSede = '{{ 'labels.citaSede'|trans([], 'LocalizationBundle') }}';
        var horaCita = '{{ 'labels.horaCita'|trans([], 'LocalizationBundle') }}';
        var horaFinal = '{{ 'labels.horaFinal'|trans([], 'LocalizationBundle') }}';
        var duracion = '{{ 'labels.duracion'|trans([], 'LocalizationBundle') }}';
        var comments = '{{ 'labels.comments'|trans([], 'LocalizationBundle') }}';
        var otraSede = '{{ 'messages.otraSede'|trans([], 'LocalizationBundle') }}';
        var pleaseWait = '{{ 'messages.pleaseWait'|trans([], 'LocalizationBundle') }}';
        {#var SrcGif = '{{ asset('bundles/utilities/images/anim_gif.gif') }}';#}
        var allData = '{{ 'messages.allData'|trans([], 'LocalizationBundle') }}';
        var sinCita = '{{ 'labels.sinCita'|trans([], 'LocalizationBundle') }}';
        var citaOk = '{{ 'messages.selectAppointmentSuccess'|trans([], 'LocalizationBundle') }}';
        var citaError = '{{ 'messages.selectAppointmentError'|trans([], 'LocalizationBundle') }}';
        var modificarValorEstudio = '{{ 'messages.modificarValorEstudio'|trans([], 'LocalizationBundle') }}';
        {#var convenios= '<option value="">{{ 'button.select'|trans([], 'LocalizationBundle') }}</option>';#}

        var urlConsultaConvenios = '{{ path('ConveniosLista') }}';
        var urlConsultaConveniosFacturables = '{{ path('ContratosFacturables') }}';
        var urlConsultaValoresContratos = '{{ path('ValoresContratos') }}';
        var urlConsultaContratosEstudios = '{{ path('receiveEstudiosContratos') }}';
        var urlConsultaValoresConvenios = '{{ path('ValoresConvenios') }}';
        var UrlConsultarModalidadesConvenio = '{{ path('hiruko_consultar_modalidades_convenios') }}';
        var urlRangosMonto = '{{ path("alert_monto") }}';
        var urlAlertModalidad = '{{ path("alert_modalidad") }}';
        var urlConsultaFechaContratos = '{{ path('contratos_val_valores') }}';
        /**
         * esta es la condición para aplicar la parte de facturación dependiendo de la parametrizaci�n utilizada actualmente.
         * @type {string}
         */

        var facturacion = '{{ facturacion }}';
        var factura_cafam = '{{ factura_cafam }}';
        var factura_convenio = '{{ factura_convenio }}';
        var contratos = '';
        var signo = "$ ";
        var dec = 2;
        var recepcion = true;
        var cliente = '{{ id_cliente }}';
        if (cliente == "RIS-DPI") {
            signo = "S/ ";
            dec = 2;
        }
        {% if(facturacion=='true') %}
        {% if(factura_cafam=='true') %}
        {var convenios= '<option value="">{{ 'button.select'|trans([], 'LocalizationBundle') }}</option>';
        {% for convenio in convenios %}
        convenios += '<option value="{{ convenio.idEps }}*{{ convenio.municipio }}">{{ convenio.name }}</option>';
        {% endfor %}}

        {#var conveniosContratos = '<option value="">{{ 'receive.select'|trans([], 'LocalizationBundle') }}</option>';
        {% for convenioContrato in conveniosContratos %}
        conveniosContratos += '<option value="{{ convenioContrato.idEps }}">{{ convenioContrato.name }}</option>';
        {% endfor %}#}
        {% elseif(factura_convenio=='true') %}

        var contratos = '<option value="">{{ 'receive.select'|trans([], 'LocalizationBundle') }}</option>';
        {% for contrato in contratos %}
        contratos += '<option value="{{ contrato.idContratos }}">{{ contrato.name }} - {{ contrato.nombreContrato }}</option>';
        {% endfor %}
        var convenios = '<option value="">{{ 'button.select'|trans([], 'LocalizationBundle') }}</option>';
        {% for convenio in convenios %}
        convenios += '<option value="{{ convenio.idEps }}">{{ convenio.name }}</option>';
        {% endfor %}

        {% else %}

        var convenios = '<option value="">{{ 'button.select'|trans([], 'LocalizationBundle') }}</option>';
        {% for convenio in convenios %}
        convenios += '<option value="{{ convenio.idEps }}">{{ convenio.name }}</option>';
        {% endfor %}

        /*{# var contratos = '<option value="">{{ 'receive.select'|trans([], 'LocalizationBundle') }}</option>';
                {% for contrato in contratos %}
                contratos += '<option value="{{ contrato.idContratos }}">{{  contrato.name }} - {{ contrato.nombreContrato }}</option>';
                {% endfor %}#}
                */
        {% endif %}

        {% else %}

        var convenios = '<option value="">{{ 'button.select'|trans([], 'LocalizationBundle') }}</option>';
        {% for convenio in convenios %}
        convenios += '<option value="{{ convenio.idEps }}">{{ convenio.name }}</option>';
        {% endfor %}

        {% endif %}
        /**
         * fin de parametrizaci�n
         * @type {string}
         */
        var Radiologos = '<option value="">{{ 'button.select'|trans([], 'LocalizationBundle') }}</option>';
        {% for rad in radiol %}
        Radiologos += '<option value="{{ rad.id }}">{{ rad.firstname }} {{ rad.lastname }}</option>';
        {% endfor %}
        var SrcGif = '{{ asset('bundles/utilities/images/anim_gif.gif') }}';
        var Sede = '{{ app.session.get('headquarter') }}';

    </script>
    <style>
        body {
            background: white;
        }

        .hir_body {
            color: black;
            font-size: 14px;
            background: #f5f5f5;
        }

        .row {
            margin-bottom: 10px;
        }

        .mt-20 {
            margin-top: 20px;
        }

        .modal-dialog {
            width: 80%;
            margin: 30px auto;
        }

        .appSelected {
            border: 3px solid #337ab7;
        }
        .error{
            border:2px solid #FF0000;
        }
        .modal-dialog {
            z-index: 4000 !important;
        }

    </style>

{% endblock %}
{% block content %}

    <div class="modal fade" id="modalDataSend" data-backdrop="static" data-keyboard="false" data-show="true">
        <div class="modal-dialog">
            <div class="modal-content">
                <div class="modal-header">
                    <h4 class="modal-title">{{ 'labels.personData'|trans([], 'LocalizationBundle') }}</h4>
                </div>
                <div class="modal-body">
                    <div class="container-fluid">
                        <form class="form-horizontal">
                            {#{{ render(url('receive_ScheduledAppointment_ViewDataSendScheduledAppointment')) }}#}
                        </form>
                    </div>
                </div>
            </div><!-- /.modal-content -->
        </div><!-- /.modal-dialog -->
    </div><!-- /.modal -->

    {% if (facturacion=='true') %}

        <div class="modal fade" id="modalDataFact" data-keyboard="false" data-show="true">
            <div class="modal-dialog" style="width: 30%">
                <div class="modal-content">
                    <div class="modal-header">
                        <h4 class="modal-title"></h4>
                    </div>
                    <div class="modal-body" align="center">
                        <div class="container-fluid" id="dataFact">
                        </div>
                    </div>
                </div><!-- /.modal-content -->
            </div><!-- /.modal-dialog -->
        </div><!-- /.modal -->

    {% endif %}

    {# Inicio Container fluid #}
    <div class="container-fluid">
    {# Contenido Tab #}
    <div class="tab-content">



    <div class="panel panel-default">
        <div class="panel-body">
            {#Datos Paciente#}
            {{ render(controller('PatientBundle:Patient:index')) }}
            {#Fin Datos Paciente#}
        </div>
    </div>


    <div class="clearfix"></div>
    {# Btn Buscar Citas #}


    {#Citas Agendadas#}
    {#<h3 id="fechaCitas">{{ 'labels.appointmentSchedule'|trans([], 'LocalizationBundle') }}</h3>#}
    <div id="citasAgendadas">

    </div>
    {#Fin Citas Agendadas#}
    <div class="clearfix"></div>


    {#************************************************************************************#}
    <div class="clearfix"></div>
    <input type="hidden" id="contratosD">
    <input type="hidden" id="convenioD">
    <input type="hidden" id="valorTotalD">
    <input type="hidden" id="valorNetoD">
    <input type="hidden" id="copagoD">
    {% if(facturacion=='true') %}
        {# Notificación de resoluciones #}
        <div class="panel panel-default cl_resoluciones hideWorkFlow hide">
            <div class="panel-body">
                <h3>Facturación</h3>
                <div class="clearfix">
                    <hr>
                </div>
                <div class="clearfix cl_resoluciones">
                    <div class="col-md-6 alert alert-success alertCotratos" id="resoluciones" role="alert"></div>
                    <div class="col-md-6 alert alert-success alertCotratos" id="resolucionesF" role="alert"></div>
                    <div class="col-md-6 alert alert-success alertCotratos" id="contratosVal" role="alert"></div>
                    <div class="col-md-3 alert alert-success alertCotratos" id="rangoMonto" role="alert"></div>
                </div>
                <div class="clearfix">
                    <hr>
                </div>
                {# Fin Notificación resoluciones #}

                <div class="row">
                    <div class="col-md-6">
                        <label for="style" class="col-md-4">Tarifas : </label>

                        <label id="tarifa_estudio" class="col-md-8">

                        </label>
                        <input type="hidden" id="valores_estudio" value=" ">
                        <span id="tarifas_estudios"></span>
                    </div>
                </div>
                <div class="row">
                    <div class="col-md-6" >
                        <label for="style" class="col-md-4">Insumos : </label>
                        <div id="insumos_estudio" class="col-md-8">
                        </div>
                    </div>
                </div>
                <div class="row">
                    {#Fin Comentarios Factura#}
                    <div class="col-md-6">
                        <label for="style" class="col-md-4" >Valores : </label>

                        <label class="col-md-8" id="valor_total">

                        </label>
                    </div>

                    {% if (id_cliente== 'RIS-DPI') %}
                        <div class="col-md-6">
                            <label for="style" >Valor paciente: </label>

                            <label class=" " id="valor_paciente"></label>
                        </div>
                    {% endif %}
                </div>
                <div class="row">
                    {#Comentarios Factura  #}
                    <div class="col-md-6" id="divComentarios">
                        <label for="style" class=" col-md-4"
                               id="lbl_comentarios">{{ 'labels.comentarios_fact'|trans([], 'LocalizationBundle') }}:
                            (*)</label>
                        <div class="col-md-8">
                            <textarea id="input_comentarios" class="form-control"  ></textarea>
                        </div>
                    </div>
                </div>
                <div class="row" id="cuotasd" ></div>
                <div class="clearfix">
                    <hr>
                </div>
                {#tipo Afiliación#}
                <div id="tipo_facturar" class="row divAfilia">
                    <div class="col-md-6">
                        <label for="style" class="col-sm-4 control-label">Tipo de afiliaci&oacute;n: (*)</label>
                        <div class="col-sm-8">
                            <select id="select_tipo_afiliacion" name="select_tipo_afiliacion"
                                    class="form-control selectpicker" data-actions-box="true"
                                    data-id="selTipoAfiliacion"
                                    title="{{ 'receive.select'|trans([], 'LocalizationBundle') }}">
                                <option value="Ex">Excluido</option>
                                <option value="Ct">Cotizante</option>
                                <option value="Bf">Beneficiario</option>
                            </select>
                        </div>
                    </div>
                    {#Fin tipo afiliación#}

                    {#nivel Afiliacion#}
                    <div class="col-md-6">
                        <label for="style" class="col-sm-4 control-label">Nivel de afiliaci&oacute;n: (*)</label>
                        <div class="col-sm-8">
                            <select id="select_nivel_afiliacion" name="select_nivel_afiliacion"
                                    class="form-control selectpicker" data-actions-box="true"
                                    data-id="selNivelAfiliacion"
                                    title="{{ 'receive.select'|trans([], 'LocalizationBundle') }}">
                                <option value="1">Nivel 1</option>
                                <option value="2">Nivel 2</option>
                                <option value="3">Nivel 3</option>
                            </select>
                        </div>
                    </div>
                    {#Fin nivel afiliacion#}
                {#</div>
                <div id="tipo_facturar" class="row divAfilia">#}
                    <div class="row" ></div>
                    {#valor Copago-Cuota Moderadora#}
                    <div class="col-md-6">
                        <div class="form-group">
                            <label for="style" class="col-sm-4 control-label">Valor Copago-Cuota
                                Moderadora: (*)</label>

                            <div class="col-sm-8">
                                <input id="valor_Copago_CuotaModeradora"
                                       name="valor_Copago_CuotaModeradora"
                                       class="form-control field_receive" type="text"
                                       oninput="this.value = this.value.replace(/[^0-9.]/g, ''); this.value = this.value.replace(/(\..*)\./g, '$1');">
                                <input id="v_cp_cm" type="hidden">
                                <input id="v_real" type="hidden">
                            </div>
                        </div>
                    </div>
                    {#Fin Copago-Cuota Moderadora#}

                    {#redondedo#}
                    <div class="col-md-6">
                        <div class="form-group">
                            <label for="style" class="col-sm-4 control-label">Redondeo:</label>

                            <div class="col-sm-8">
                                <select id="select_redondeo" name="select_redondeo"
                                        class="form-control selectpicker" data-actions-box="true"
                                        data-id="selNivelAfiliacion"
                                        title="{{ 'receive.select'|trans([], 'LocalizationBundle') }}">
                                </select>
                            </div>
                        </div>
                    </div>
                    {#Fin redondeo#}
                </div>
                <div class="clearfix">
                    <hr>
                </div>

                {# inicio tipo_pago#}
                <div class="row">
                    {#codigo autorización#}
                    <div class="col-md-6" id="divCodigoAutorizacion">
                        <div class="form-group">
                            <label for="style" class="col-sm-4 control-label"
                                   id="lbl_codigo_autorizacion">{{ 'labels.codAutorizacion'|trans([], 'LocalizationBundle') }}
                                :(*)</label>
                            <div class="col-sm-8">
                                <input type="text" name="" id="input_codigo_autorizacion" class="form-control"/>
                            </div>
                        </div>
                    </div>
                    {#Fin codigo autorización#}

                    {#poliza soat#}
                    <div class="col-md-6" id="divPolizaSoat">
                        <div class="form-group">
                            <label for="style" class="col-sm-4 control-label"
                                   id="lbl_poliza_soat">{{ 'labels.polizaSoat'|trans([], 'LocalizationBundle') }}:
                                (*)</label>
                            <div class="col-sm-8">
                                <input type="text" name="" id="input_poliza_soat" class="form-control"/>
                            </div>
                        </div>
                    </div>
                    {#Fin poliza soat#}
                </div>
                <div class="clearfix" style="margin-bottom:10px;"></div>
                <div class="row">

                    <div class="col-md-6">
                        <div class="col-md-12">
                            <label class="col-sm-4">Tipo de pago:</label>
                            <div class="col-sm-8 checkbox">
                                {#<label class="checkbox-inline"><input type="radio" name="tipo_pago_d" value="Efectivo"#}
                                                                    {#checked="checked">Efectivo</label>#}

                                {#<label class="checkbox-inline"><input type="radio" name="tipo_pago_d" value="Tarjeta">Tarjeta</label>#}

                                {#<label class="checkbox-inline"><input type="radio" name="tipo_pago_d" value="Mixto">Mixto</label>#}
                                <select id="tipo_pago_d" name="forma_pago" class="form-control selectpicker required">
                                    <option value="">{{ 'button.select'|trans([], 'LocalizationBundle') }}</option>
                                    <option value="Efectivo">Efectivo</option>
                                    <option value="Tarjeta">Tarjeta</option>
                                    <option value="Mixto">Mixto</option>
                                </select>

                            </div>
                        </div>
                        <div class="col-md-12" id="div_valor_tarjeta">
                            <label class="col-sm-4">Valor tarjeta:
                            </label>
                            <div class="col-sm-8">
                                <input id="valor_credito" maxlength="10"
                                    oninput="this.value = this.value.replace(/[^0-9.]/g, ''); this.value = this.value.replace(/(\..*)\./g, '$1');"
                                    class="form-control" name="valor_tarjeta" type="text">
                            </div>
                        </div>
                        <div class="col-md-12" id="div_valor_efectivo">
                            <label class="col-sm-4">Valor efectivo:
                            </label>
                            <div class="col-sm-8">
                                <input id="valor_efectivo" maxlength="10"
                                    oninput="this.value = this.value.replace(/[^0-9.]/g, ''); this.value = this.value.replace(/(\..*)\./g, '$1');"
                                    class="form-control" name="valor_efectivo" type="text">
                            </div>

                        </div>
                    </div>

                    <div class="col-md-6">
                        <div class="col-md-12" id="div_descuento">
                            <label class="col-sm-4">Descuento:</label>
                            <div class="col-sm-8">
                                <input id="descuento" maxlength="10" value="0"
                                    oninput="this.value = this.value.replace(/[^0-9.]/g, ''); this.value = this.value.replace(/(\..*)\./g, '$1');"
                                    class="form-control" name="descuento" type="text">
                            </div>
                        </div>
                        <div class="col-md-12" id="div_valor_bono">
                            <label class="col-sm-4">Bono:</label>
                            <div class="col-sm-8">
                                <input id="valor_bono" maxlength="10" value="0"
                                    oninput="this.value = this.value.replace(/[^0-9.]/g, ''); this.value = this.value.replace(/(\..*)\./g, '$1');"
                                    class="form-control" name="valor_bono" type="text">
                            </div>
                        </div>
                    <input id="valor_paciente" type="hidden">

                </div>

            </div>
        </div>


    {% endif %}
    {#************************************************************************************#}

    <div class="panel panel-default hideWorkFlow hide">
        <div class="panel-body">
            <h3></h3>
            <div class="clearfix">
                <hr>
            </div>
            <div class="row">
                {#check Sin Lectura#}
                <div class="col-md-1">
                    <div class="checkbox col-md-12">
                        <label for="style" class="control-label"> 
                            <input type="checkbox" id="sinLectura" value=" " name="sinLectura">{{ 'receive.sin_lectura'|trans([], 'LocalizationBundle') }}
                        </label>
                    </div>
                </div>
                {# Fin check Sin Lectura#}
                <div class="col-md-1">
                    <div class="checkbox col-md-12">
                        <label for="style" class="control-label"> 
                            <input type="checkbox" id="investigacion" value=" " name="investigacion" onchange="checkboxInvestigacion()">Investigación
                        </label>
                    </div>
                </div>
                {#trae info clinica#}
                <div class="col-md-6 col-md-offset-4">
                    <div class="form-group">
                        <label for="style"
                               class="col-sm-4">{{ 'labels.patient.clinicalData'|trans([], 'LocalizationBundle') }}
                            :</label>
                        <div class="col-sm-8">
                            <div class="radio">
                                <label class="col-sm-6">
                                    <input type="radio" name="clinicalData_receiveAppointment"
                                           id="clinicalData_receiveAppointment" value="1" checked="checked"
                                               >
                                    {{ 'labels.yes'|trans([], 'LocalizationBundle') }}
                                </label>
                            </div>
                            <div class="radio">
                                <label class="col-sm-6">
                                    <input type="radio" name="clinicalData_receiveAppointment" value="2" id="clinicalData_receiveAppointment_no"
                                           >
                                    {{ 'labels.no'|trans([], 'LocalizationBundle') }}
                                </label>
                            </div>
                        </div>
                    </div>
                </div>
                {#Fin trae info clinica#}
            </div>
            <div class="row">
                {#FOLIO - CONSECUTIVO#}
                {% if folio_consecutive == 'true' %}
                    <div class="col-md-6">
                        <div class="form-group">
                            <label class="col-sm-4 control-label">{{ 'labels.folio'|trans([], 'LocalizationBundle') }}
                                :</label>
                            <div class="col-sm-8">
                                <input id="input_folio_receive" class="form-control" name="input_folio_receive"
                                       type="text" value="" title="" onkeyup="">
                            </div>
                        </div>
                    </div>
                {% endif %}
                {% if consecutive == 'true' %}
                    <div class="col-md-6">
                        <div class="form-group">
                            <label class="col-sm-4 control-label">{{ 'labels.consecutive'|trans([], 'LocalizationBundle') }}
                                &nbsp;*:</label>
                            <div class="col-sm-8">
                                <input id="input_consecutive_receive" class="form-control"
                                       name="input_consecutive_receive" type="text" value="" title="" onkeyup="">
                            </div>
                        </div>
                    </div>
                {% endif %}
            </div>
            <div class="row">
                {#prioridad#}
                <div class="col-md-6">
                    <div class="form-group">
                        <label for="style" class="col-sm-4">{{ 'labels.priority'|trans([], 'LocalizationBundle') }}:
                            (*)</label>
                        <div class="col-sm-8">
                            <select id="select_priority_receiveAppointment" name="select_priority_receiveAppointment2222"
                                    class="form-control selectpicker required">
                                <option value="">{{ 'button.select'|trans([], 'LocalizationBundle') }}</option>
                                {% for priority in priList %}
                                    <option value="{{ priority.priId }}">{{ priority.priName }}</option>
                                {% endfor %}
                            </select>
                        </div>
                    </div>
                </div>
                {#Fin prioridad#}

                <div class="col-md-6">
                    {# Medico remitente #}
                    <div class="form-group">
                        <label class="col-sm-4">{{ 'assistive.attendingphysician.label'|trans([], 'LocalizationBundle') }}
                            : *</label>

                        <div class="col-sm-6" id="divrefDoc">
                            <select name="doctor_referring" id="doctor_referring" class="form-control selectpicker">
                                {% for remitentes in medicoRemitente %}
                                    <option value="{{ remitentes.id }}">{{ remitentes.firstName }} {{ remitentes.lastName }}</option>
                                {% endfor %}
                            </select>
                        </div>
                        <div class="col-sm-2">
                            <a class="btn btn-primary" data-toggle="modal" data-target="#myModal">
                                {{ 'button.new'|trans([], 'LocalizationBundle') }}
                            </a>
                        </div>
                    </div>
                </div>
            </div>
            <div class="row">
                <div class="form-group">
                    <div class="col-sm-6">
                        <label class="col-md-4">{{ 'labels.filtroCIE10'|trans([], 'LocalizationBundle') }}</label>
                        <div class="col-sm-6">
                            <input type="text" name="filtroCIE10" id="filtroCIE10" class="form-control"
                                   placeholder="{{ 'labels.filtroCIE10'|trans([], 'LocalizationBundle') }}"/>
                        </div>
                        <div class="col-sm-2">
                            <a id="filterSearch"
                               class="btn btn-default form-control">{{ 'labels.filtroCIE10'|trans([], 'LocalizationBundle') }}</a>
                        </div>
                        <div class="col-sm-8 col-md-offset-4" id="divCie10">
                            <select id="select_cie10" name="select_cie10" class="form-control selectpicker"
                                    data-actions-box="true" data-id="selCIE" data-style="btn-default"
                                    data-live-search="true"
                                    title="{{ 'button.select'|trans([], 'LocalizationBundle') }}">

                            </select>
                        </div>
                    </div>
                </div>
            </div>

            <div class="row mt-20">
                {#orden medica#}
                <form id="registerReceiveAppointment" name="registerReceiveAppointment" enctype="multipart/form-data"
                      method="post">
                    <div class="col-md-6">
                        <div class="form-group">
                            <label class="col-sm-4">{{ 'labels.patient.orden'|trans([], 'LocalizationBundle') }}
                                :</label>
                            <div class="col-sm-8">
                                <input id="file_Clinical_Order_receiveAppointment" class="form-control"
                                       name="file_Clinical_Order_receiveAppointment" type="file">
                            </div>
                        </div>
                    </div>
                </form>
                {#Fin orden medica#}
            </div>
            {#Modal medico Remitente#}
            <div class="modal fade" id="myModal" role="dialog">
                <div class="modal-dialog">
                    <div class="modal-content">
                        <div class="modal-header">
                            <button type="button" class="close" data-dismiss="modal">&times;</button>
                            <h4 class="modal-title">Register Doctor Referring</h4>
                        </div>
                        <div class="modal-body">
                            {{ render(controller('HirukoAdminBundle:Referring:index')) }}
                        </div>
                    </div>
                </div>
            </div>
            {#Fin Modal medico Remitente#}
        </div>
    </div>



    <div class="col-md-12">
        <hr>
    </div>

    <div class="clearfix"></div>





    {# Botones para enviar al flujo de trabajo #}
    <div class="hideWorkFlow hide">
        <button class="btn btn-default" style="margin-right:20px;" id= "Btcancelar"><span class="glyphicon glyphicon-remove" aria-hidden="true"></span> {{ 'button.cancel'|trans([], 'LocalizationBundle') }}
        </button>
        <button id="saveReceiveAppointment"
                class="btn btn-primary"> {{ 'labels.action.enviarEstudio'|trans([], 'LocalizationBundle') }} </button>
    </div> {#Fin Botones#}
    </div>{# Fin Contenido Tab #}
    {#</div> Fin Wizard #}
    {#</div> Fin panel body #}
    {#</div> Fin panel #}
    </div>{# Fin Container fluid #}

{% endblock %}