{% if facility %}
{{ facility.name }}
{{ facility.address_line1 }}{% if facility.address_line2 %}, {{ facility.address_line2 }}{% endif %}, {{ facility.city }}, {{ facility.state }} {{ facility.postal_code }} {% if facility.phone %} · Tel {{ facility.phone }}{% endif %} {% if facility.fax %} · Fax {{ facility.fax }}{% endif %}
{% endif %}
{{ patient_name }} {% if dob %} · DOB {{ dob }}{% endif %} {% if age %} ({{ age }}){% endif %} {% if patient.sex %} · {{ patient.sex }}{% endif %} · Date of service: {{ dos }} {% if encounter.note_type %} · {{ encounter.note_type }}{% endif %}
{% if encounter.chief_complaint %}
Chief complaint: {{ encounter.chief_complaint }}
{% endif %}
{% for section in note_sections %}

{{ section.title or "Note" }}

{# Source note HTML is rendered as authored; print CSS cannot run scripts and Chromium renders with no network access to leak to. #}
{{ section.html | safe if section.html else section.text }}
{% endfor %} {% if vitals %}

Vitals

{% for v in vitals %} {% endfor %}
MeasureValueUnit
{{ v.display or v.code }}{{ v.value }}{{ v.unit or "" }}
{% endif %} {% if social_history %}

Social history

{% for o in social_history %} {% endfor %}
{{ o.display }}{{ o.value }}
{% endif %} {% if coverages %}

Payment information

{% for c in coverages %} {% endfor %}
OrderPayerPlanTypeMember ID
{{ c.priority_label or "" }}{{ c.payer or "" }} {{ c.plan_name or "" }}{{ c.plan_type or c.coverage_type or "" }} {{ c.member_id or "" }}
{% endif %} {% if addenda %}

Addenda

{% for addendum in addenda %}
{{ addendum.text }}
{{ addendum.status or "" }}{% if addendum.source %} · {{ addendum.source }}{% endif %}
{% endfor %} {% endif %}