{% block content %}
    <script>
        var referring_id_mandatory = {{ (referring_id_mandatory) ? 'true' : 'false'}};
    </script>
    <script src="{{ asset('bundles/hirukoadmin/js/ajax/referring.js') }}"></script>
    <div class="panel panel-default" id="_dr_rm">
        <div class="panel-body">
            <form id="__form__create__dr__" name="__form__create__dr__" method="post" autocomplete="off">

                <div class="row mt-1">
                    {% if ris_internacional %}
                        <div class="col-md-6">
                            <div class="form-group __title__dr__">
                                <label for="style"
                                       class="col-sm-6 control-label">{{ 'labels.role.title'|trans([], 'LocalizationBundle') }}
                                    :</label>
                                <div class="col-sm-6">
                                    <input maxlength="10" name="title_referring" id="title_referring"
                                           class="form-control"
                                           type="text"
                                           value="">
                                </div>
                            </div>
                        </div>
                    {% endif %}
                    {% if ris_internacional == false %}
                        <div class="col-md-6">
                            <div class="form-group">
                                <label for="style"
                                       class="col-sm-6 control-label">{{ 'Query.typeDocument.label'|trans([], 'LocalizationBundle') }}
                                    :</label>
                                <div class="col-sm-6">
                                    <select name="documentType" id="documentType" class="form-control">
                                        {% for document in docType %}
                                            <option value="{{ document }}">{{ document }}</option>
                                        {% endfor %}
                                    </select>
                                </div>
                            </div>
                        </div>
                    {% endif %}
                </div>
                <div class="row mt-1">
                    <div class="col-md-6">
                        <div class="form-group __provider__number__dr__">
                            <label for="style"
                                   class="col-sm-6 control-label">{{ 'labels.role.providerNum'|trans([], 'LocalizationBundle') }}
                                :</label>
                            <div class="col-sm-6">
                                <input name="providerNumber" id="providerNumber" class="form-control field_receive"
                                       type="text"
                                       value="">
                            </div>
                        </div>
                    </div>
                    <div class="col-md-6">
                        <div class="form-group __first__name__dr__">
                            <label for="style"
                                   class="col-sm-6 control-label">{{ 'assistive.name.label'|trans([], 'LocalizationBundle') }}
                                :</label>
                            <div class="col-sm-6">
                                <input name="firstName_referring" id="firstName_referring" class="form-control"
                                       type="text"
                                       onkeyup="javascript:this.value=this.value.toUpperCase();" value="">
                            </div>
                        </div>
                    </div>
                </div>
                <div class="row mt-1">
                    <div class="col-md-6">
                        <div class="form-group __last__name__dr__">
                            <label for="style"
                                   class="col-sm-6 control-label">{{ 'schedule.lastNamePatient'|trans([], 'LocalizationBundle') }}
                                :</label>
                            <div class="col-sm-6">
                                <input name="lastName_referring" id="lastName_referring" class="form-control"
                                       type="text"
                                       onkeyup="javascript:this.value=this.value.toUpperCase();" value="">
                            </div>
                        </div>
                    </div>
                    {% if ris_internacional %}
                        <div class="col-md-6">
                            <div class="form-group">
                                <label for="style"
                                       class="col-sm-6 control-label">{{ 'labels.role.practiceName'|trans([], 'LocalizationBundle') }}
                                    :</label>
                                <div class="col-sm-6">
                                    <input maxlength="80" name="practiceName" id="practiceName" class="form-control"
                                           type="text" value="">
                                </div>
                            </div>
                        </div>
                    {% endif %}
                </div>
                <div class="row mt-1">
                    <div class="col-md-6">
                        <div class="form-group">
                            <label for="style"
                                   class="col-sm-6 control-label">{{ 'labels.specialty'|trans([], 'LocalizationBundle') }}
                                :</label>
                            <div class="col-sm-6">
                                <input maxlength="30" name="specialised_field" id="specialised_field"
                                       class="form-control" type="text"
                                       value="">
                            </div>
                        </div>
                    </div>
                    <div class="col-md-6">
                        <div class="form-group __delivery__report__dr__">
                            <label for="style"
                                   class="col-sm-6 control-label">{{ 'labels.deliveryPreference'|trans([], 'LocalizationBundle') }}
                                :</label>
                            <div class="col-sm-6">
                                <select name="delivery_report" id="delivery_report" class="form-control">
                                    <option value="2">HL7</option>
                                    <option value="1">Fax</option>
                                    <option value="0">Courier</option>
                                </select>
                            </div>
                        </div>
                    </div>
                </div>
                <div class="row mt-1">
                    <div class="col-md-6">
                        <div class="form-group __address__dr__">
                            <label for="style"
                                   class="col-sm-6 control-label">{{ 'labels.patient.address'|trans([], 'LocalizationBundle') }}
                                1:</label>
                            <div class="col-sm-6">
                                <input name="address" id="address_referring" class="form-control" type="text" value="">
                            </div>
                        </div>
                    </div>
                    <div class="col-md-6">
                        <div class="form-group">
                            <label for="style"
                                   class="col-sm-6 control-label">{{ 'labels.patient.address'|trans([], 'LocalizationBundle') }}
                                2:</label>
                            <div class="col-sm-6">
                                <input maxlength="29" name="address2" id="address2" class="form-control" type="text"
                                       value="">
                            </div>
                        </div>
                    </div>
                </div>
                <div class="row mt-1">
                    <div class="col-md-6">
                        <div class="form-group">
                            <label for="style"
                                   class="col-sm-6 control-label">{{ 'mail.email'|trans([], 'LocalizationBundle') }}
                                :</label>
                            <div class="col-sm-6">
                                <input name="email_referring" id="email_referring" class="form-control" type="text"
                                       value="">
                            </div>
                        </div>
                    </div>
                    <div class="col-md-6">
                        <div class="form-group __code__postal__dr__">
                            <label for="style"
                                   class="col-sm-6 control-label">{{ 'labels.postCode'|trans([], 'LocalizationBundle') }}
                                :</label>
                            <div class="col-sm-6">
                                <input maxlength="4" name="postal_referring" id="postal_referring" class="form-control"
                                       type="text"
                                       value="">
                            </div>
                        </div>
                    </div>
                </div>
                {% if ris_internacional %}
                    <div class="row mt-1">
                        <div class="col-md-6">
                            <div class="form-group __state__dr__">
                                <label for="style" class="col-sm-6 control-label">State:</label>
                                <div class="col-sm-6">
                                    <input maxlength="4" name="state_referring" id="state_referring"
                                           class="form-control" type="text"
                                           value="">
                                </div>
                            </div>
                        </div>
                        <div class="col-md-6">
                            <div class="form-group __suburb__dr__">
                                <label for="style"
                                       class="col-sm-6 control-label">{{ 'labels.suburb'|trans([], 'LocalizationBundle') }}
                                    :</label>
                                <div class="col-sm-6">
                                    <input maxlength="29" name="suburb" id="suburb_referring" class="form-control"
                                           type="text" value="">
                                </div>
                            </div>
                        </div>
                    </div>
                {% endif %}
                <div class="row mt-1">
                    <div class="col-md-6">
                        <div class="form-group">
                            <label for="style"
                                   class="col-sm-6 control-label">{{ 'patient.telephone.label'|trans([], 'LocalizationBundle') }}
                                - {{ 'utilities.business'|trans([], 'LocalizationBundle') }}:</label>
                            <div class="col-sm-6">
                                <input maxlength="255" name="telBusiness" id="telBusiness" class="form-control"
                                       type="text" value="">
                            </div>
                        </div>
                    </div>
                    <div class="col-md-6">
                        <div class="form-group">
                            <label for="style"
                                   class="col-sm-6 control-label">{{ 'patient.telephone.label'|trans([], 'LocalizationBundle') }}
                                - {{ 'utilities.home'|trans([], 'LocalizationBundle') }}:</label>
                            <div class="col-sm-6">
                                <input maxlength="80" name="telHome" id="telHome" class="form-control" type="text"
                                       value="">
                            </div>
                        </div>
                    </div>
                </div>
                <div class="row mt-1">
                    <div class="col-md-6">
                        <div class="form-group">
                            <label for="style"
                                   class="col-sm-6 control-label">{{ 'labels.patient.fax'|trans([], 'LocalizationBundle') }}
                                - {{ 'utilities.business'|trans([], 'LocalizationBundle') }}:</label>
                            <div class="col-sm-6">
                                <input maxlength="16" name="fax" id="fax" class="form-control" type="text" value="">
                            </div>
                        </div>
                    </div>
                    <div class="col-md-6">
                        <div class="form-group">
                            <label for="style"
                                   class="col-sm-6 control-label">{{ 'labels.patient.cel'|trans([], 'LocalizationBundle') }}
                                :</label>
                            <div class="col-sm-6">
                                <input name="mobile" id="mobile" class="form-control" type="text" value="">
                            </div>
                        </div>
                    </div>
                </div>
                <div class="alert alert-success hide" id="doctorOK" role="alert"><strong><span
                            class="glyphicon glyphicon-ok"></span> {{ 'messages.processOk'|trans([], 'LocalizationBundle') }}
                    </strong></div>
                <div class="col-md-12 mt-1">
                    <div class="pull-right">
                        <a href="#" class="btn btn-primary"
                           id="__create__dr__">{{ 'button.save'|trans([], 'LocalizationBundle') }}</a>
                        <a href="#" class="btn btn-default" id="__cancel__save__dr" data-toggle="modal"
                           data-target="#myModal">{{ 'button.cancel'|trans([], 'LocalizationBundle') }}</a>
                    </div>

                </div>

            </form>
        </div>
    </div>
    <div class="clearfix"></div>
    <script>
        var ris_internacional = '{{ ris_internacional }}';
    </script>
{% endblock %}