<h3>Fulfills the Following Veteran Request:</h3>
<% if (requestedPhoneCall) { %>
<p class="error-message"><span class="alert-icon"></span><span>Patient has requested a phone call: <%- phoneNumber %></span></p>
<% }%>
<div>
    <span>Type of Care</span>
    <span><%- appointmentType %></span>
</div>
<div>
    <span>Provider</span>
    <span><%- providerName %></span>
</div>
<div data-role="fieldcontain">
    <fieldset id="request-date-time" data-role="controlgroup">
        <legend>Request Date/Time</legend>
        <input type="radio" name="options" id="option-date1" value="<%- optionDate1 %> <%- optionTime1 %>">
        <label for="option-date1"><%- optionDate1 %><% if (optionTime1 !== "No Time Selected") { %> <%- optionTime1 %><% } %></label>
        <% if (optionDate2 !== "No Date Selected") { %>
        <input type="radio" name="options" id="option-date2" value="<%- optionDate2 %> <%- optionTime2 %>">
        <label for="option-date2"><%- optionDate2 %> <%- optionTime2 %></label>
        <% } %>
        <% if (typeof optionDate3 !== "undefined" && optionDate3 && optionDate3 !== "No Date Selected") { %>
            <input type="radio" name="options" id="option-date3" value="<%- optionDate3 %> <%- optionTime3 %>">
            <label for="option-date3"><%- optionDate3 %> <%- optionTime3 %></label>
        <% } %>
        <input type="radio" name="options" id="alternate-call-patient" value="DETCODE2">
        <label for="alternate-call-patient">Booked from alternate after contacting patient</label>
        <input type="radio" name="options" id="alternate-no-call" value="DETCODE12">
        <label for="alternate-no-call">Booked from alternate</label>
    </fieldset>
</div>
<% if (visitType && visitType === "Video Conference") { %>
<div data-role="fieldcontain">
    <label for="videoToPhone">Video Appt.</label>
    <select name="videoToPhone" id="videoToPhone" data-role="slider">
        <option value="off">Yes</option>
        <option value="on">No</option>
    </select>
</div>
<% } %>
