[[static_app_header.html]]



<script language="JavaScript" type="text/JavaScript">
	


function OrderValidation()
{
	if (c1() == false)
		return false;
		
	
	
/*	if(document.frm.pdel.selectedIndex == 0)
	{
		alert("Please select Delivery/Pickup");
		return false;	
	}
*
/*	if(document.frm.dte.selectedIndex == 0)
	{
		alert("Please select Delivery/Pickup Date");
		return false;	
	}
*/
/*
	if(document.frm.dptime.selectedIndex == 0)
	{
		alert("Please select Enter Delivery/Pickup Time");
		return false;	
	}
*/
	
/*	if((document.frm.pdel.selectedIndex == 2) && (document.frm.DeliveryAddress.value == ""))
	{
		alert("Please enter DeliveryAddress");
		return false;	
	}
*/

	var email = document.frm.Email.value;
/*	if(email != "")
	{*/
	if(validate_email(document.frm.Email,"invalid email") == false)
		return false;
/*	}*/
/*	if(SpecialInstructions == "")
	{
		alert("Please enter SpecialInstructions");
		return false;	
	}
*/
		
	return true;
	
	
}
function c1()
{
	for(i=0; i<document.forms[0].elements.length;i++)
	{
		if(document.forms[0].elements[i].type == "checkbox")
		{
			if (document.forms[0].elements[i].checked == true)
				return true;
		}
	}
	alert("please check at least one to refill ");
	return false;
}
function checkall(mode)
{
	for(i=0; i<document.forms[0].elements.length;i++)
	{
		if(document.forms[0].elements[i].type == "checkbox")
		{
			document.forms[0].elements[i].checked = (mode == 'y');
		}
	}
}
function validate_email(field,alerttxt)
{
with (field)
{
apos=value.indexOf("@")
dotpos=value.lastIndexOf(".")
if (apos<1||dotpos-apos<2) 
  {alert(alerttxt);return false}
else {return true}
}
}


</script>

{$error{<font color="#ff0000">$error</font>}}

{!$error{


<!-- Content Area Start -->



<div align="center">
	<table border="0" width="95%" cellspacing="0" cellpadding="0">
		<tr>
			<td width="100%" height="40">
				<div align="right">
					<table border="0" width="98%" cellspacing="0" cellpadding="0">
							<tr>
								<td class="blue-txta"><h1>Order Prescriptions</h1></td>
								<td align="right">Welcome <b> $patient_firstname $patient_lastname</b></td>
								<td width="30" align="right"><img border="0" src="$staticimages_http_prefix/security.jpg" width="14" height="16" /></td>
								<td width="45" align="right"><a href="logout.php">Logout</a></td>
							</tr>				
					</table>
				</div>    
			</td>
		</tr>
<form name="frm" action="$orderrefills_confirmation_url"  method="post" onsubmit="return OrderValidation()">

$store

<tr>
			<td width="100%" class="gray-border">	
<table border="0" width="100%" cellspacing="0" cellpadding="0"> <!--UNOPEN-->
$profile


</table>


<table border="0" width="100%" cellspacing="0" cellpadding="0">
<tr>
      <td width="100%" class="left right top bottom blued" height="40" align="center"><h2>Order Options</h2></td>
    </tr>
    <tr>
      <td width="100%" class="left right bottom">
        <div align="center">
          <center>
          <table border="0" cellspacing="0" cellpadding="0">
            <tr>
              <td height="20"></td>
              <td width="10" align="center"></td>
              <td></td>
            </tr>
            <tr>
              <td>*Delivery/Pickup</td>
              <td height="30" align="center">:</td>
              <td><select size="1" name="pdel">
									<option value="P">Pickup</option>
									<option value="D">Delivery</option>
									</select></td>
						</tr>
            <tr>
              <td>Email</td>
              <td height="30" align="center">:</td>
              <td><input type="text" name="Email" size="50" maxlength="100" value="$patients_email"></td>
            </tr>
            <tr>
              <td>Delivery Address</td>
              <td height="30" align="center">:</td>
              <td><input type="text" name="DeliveryAddress" size="50" maxlength="50" value="$patients_address"></td>
            </tr>
            <tr>
              <td>Special Instructions</td>
              <td height="30" align="center">:</td>
              <td><input type="text" name="SpecialInstructions" size="50" maxlength="50"></td>
            </tr>
            <tr>
              <td height="20"></td>
              <td align="center"></td>
              <td></td>
            </tr>
          </table>
          </center>
        </div>
      </td>
    </tr>
    <tr>
      <td width="100%" height="20"></td>
    </tr>
    <tr>
      <td width="100%"><input type="image" value="Submit" class="no-border" src="$staticimages_http_prefix/but-order-refills.jpg" width="152" height="38"></td>
    
    
    
    </tr>
    <tr>
      <td width="100%" height="30"></td>
    </tr>
  </table>


</form>
			
</td>
</tr>

}}			
	</table>
</div>    

    




[[static_footer.html]]

<<store>> 

	<tr>
			<td width="100%" class="bluef" height="40">
			<div align="center">
									<table border="0" width="95%" cellspacing="0" cellpadding="1">
											<tr>
												<td class="white-txt"><h3>$store_name</h3></td>
												<td class="white-txt" align="right"><h3>Phone: $store_phone</h3></td>
											</tr>
<tr>
<td><input class="flat" size="10" readonly="true" type="hidden" name="storeid" value="$store_storeidentifier" /></font></td></tr>
											<tr>
												<td colspan="2" class="white-txt"><h3>$store_address,  $store_city</h3></td>
											</tr>
									</table>
      </div>
      
      </td>
  </tr>


<</store>>


<<profile>> 

<tr>
	<td width="100%">
		<table border="0" width="100%" cellspacing="0" cellpadding="0">
			<tr>
				<td width="60%" rowspan="3" class="left-top-right blued" valign="top">
					<table border="0" width="100%" cellspacing="0" cellpadding="0">
						<tr>	
							<td align="center" valign="top" width="25%">
								<img border="0" src="$profile_drugpic" width="82" height="62"><!--<span class="style3"><br>Drug	Info</span>-->
							</td>
							<td valign="top" width="50%">
								<table border="0" width="100%" cellspacing="0" cellpadding="0">
									<tr>
										<td width="50%">Date: $profile_filldate</td>
										<td width="50%" align="right"><strong>Rx#: $profile_rxnumber</strong></td>
									</tr>
									<tr>
										<td width="100%" colspan="2"><b>$profile_tradename $profile_drugstrength</b></td>
									</tr>
									<tr>
										<td width="100%" colspan="2"><span class="style4">$profile_genericname &nbsp; $profile_drugstrength</span></td>
									</tr>
									<tr>
										<td width="100%" colspan="2" class="style5">$profile_doctor</td>
										<td align="left" valign="top"><font color="#e2f2f9">$profile_rxid</FONT></td>
									</tr>
									
								</table>                
							</td>
						
						</tr>
					</table>          
				</td>
        <td width="19%" class="top-right blued blue-txtb"><img src="$profile_stateimage" alt="ss"> </td>
      
      
                
      
      <td align="center" valign="middle" rowspan="3" class="top-right blued blue-txtb"> {$orderable{   <input type="checkbox" class="check" name="rxid[]" value="$profile_rxid" /><br><br>}}
<font color="red"> $profile_reason </font></td>
      
      </tr>
      <tr>
        <td width="19%" class=" top-right blued">
        	<p><b>Quantity: $profile_fillquantity<br>
        	Repeats: $profile_repeats</b></p>          
        </td>
      </tr>
      <tr>
        <td width="19%" class="top-right blued">
            <p class="style4">Authorized: $profile_quantityauthorized<br>
            Remaining: $profile_quantityremaining</p>          
        </td>
      </tr>
      
 
    </table>
  </td>
</tr>

<</profile>>


<<date_select>> 
<option>$select_item 
<</date_select>>