<div class="details">
    <h3 class="text-header-m1">Request Details</h3>

    <ul data-role='listview' data-inset='true' data-theme='c'>
        <li><span class="fieldname">Patient Name</span><span class="fieldvalue"><%- patientName %></span></li>
        <li><span class="fieldname">SSN</span><span class="fieldvalue"><%- ssn %></span></li>
        <li><span class="fieldname">Cell Phone</span><span class="fieldvalue"><%- cellPhone %></span></li>
        <li><span class="fieldname">Home Phone</span><span class="fieldvalue"><%- homePhone %></span></li>
        <li><span class="fieldname">Facility</span><span class="fieldvalue"><%- facilityId %></span></li>
        <li><span class="fieldname">Service Connected Priority</span><span class="fieldvalue"><%- serviceConnectedCode %></span></li>
        <li><span class="fieldname">Request Date</span><span class="fieldvalue"><%- appointmentRequestDate %></span></li>
    </ul>
</div>