[[static_erefill_header.html]]

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


function orderbynumbervalidation()
{
	var ValidChars = "0123456789.";
	var IsNumber=true;
	var Char;
	var telephone = document.frm.telephone.value;
	if(telephone == "")
	{
		alert("Telephone Number must be filled in and match a phone number on file at the store for each prescription");		
		return false;
	} 
	else 
	{
	 for (i = 0; i < telephone.length && IsNumber == true; i++) 
      { 
      Char = telephone.charAt(i); 
      if (ValidChars.indexOf(Char) == -1) 
         {
		   isnumber=false;	 
		   alert("Invalid Characters in Phone Number only use 0123456789");	 
           return false;
         }
      }
	  if (telephone.length!=10)
	  {
		 alert("Invalid Phone Number format shoud be 9999999999 10 digits including areacode ");
		  return false;
	  }
	}
	
//	if (validaterxs() == false)
//	{
//		return false;
//	}
		
			
	return true;
	
	
}
function validaterxs()
{
	var j =0;
	var k =0;
	var m =0;
	var txt = "";
	var storeshort ="";
	var pos=-1;
	for(i=0; i<document.forms[0].elements.length;i++)
	{

		if(document.forms[0].elements[i].type == "text")
			{
				if (document.forms[0].elements[i].name == "rxnums[]")
					{
						if (document.forms[0].elements[i].value!="") 
							{
				   			j=j+1;
				   			txt=document.forms[0].elements[i].value;
							pos=txt.indexOf("-");
							if (pos==-1)
							{
				   					k=k+1;
				   			}
							else
							{
							 if (storeshort=="")	
							 {
								 storeshort=txt.substr(pos+1);
							 }
							 if (storeshort!=txt.substr(pos+1))
							 {
								 m=m+1;
							 }
							}
							}
					}
			}
	}
	if (j==0) 
	{
		alert("please fill in at least one prescription number to refill "		);
		return false;
	}
	if (k>=1) 
	{
		alert("missing - Store on at least one prescription "		);
		return false;
	}
	if (m>=1) 
	{
		alert("please order from one store at a time "		);
		return false;
	}
	
	return true;
}





</script>





<!-- Content Area Start -->
<form id="frm" name="frm" method="post" action="orderrefillsbynumber.php" onsubmit="return orderbynumbervalidation()">
      <table border="0" width="100" cellspacing="2" cellpadding="2">


<tr>
</tr>
<tr>


<td colspan=3 class="pad-lefta blue-txta"><h1>Welcome to e-Refill</h1><br /></td>


</tr>
  

<tr>

  <td class="pad-lefta blue-txta">Pharmacy Location</td>
<td class="pad-lefta blue-txta"> Enter your Phone # (10 digit) </td>
</tr>

      <td class="pad-lefta blue-txta">  

<select name="storetelephone" tabindex="1">
               <option value="9058343514" selected="selected">Boggios Port Colborne </option>
               <option value="9058942200">Boggio and Edwards Ridgeway</option>
               <option value="9053541812">Mackinnons Niagara Falls</option>
               <option value="9058924994">Boggios Fonthill</option>

            </select>
      </td>
   
  <td class="pad-lefta blue-txta">  <input type="text" name="telephone" id="telephone" tabindex="2"> </td>
<!--  <td class="pad-lefta blue=txta"> eg:9051234567 </td> -->

<!--<input type="text" name="storetelephone" id="storetelephone" /<br>example: 4163537219-->
      </tr>

<tr>
 <td class="pad-lefta blue-txta">Delivery/Pickup</td>
 <td class="pad-lefta blue-txta">Email</td>
</tr>
<tr>
 
  <td class="pad-lefta blue-txta"><select size="1" name="pdel" tabindex="3">
	<option value="P" selected="selected">Pickup </option>
	<option value="D">Delivery</option>
   </select></td>
						
            
             
             <!-- <td height="30" align="center">:</td> -->

              <td class="pad-lefta blue-txta"><input type="text" name="email" id="email" size="50" maxlength="100" tabindex="4"></td>
           
</tr>


<tr>
      
</tr>

      
<tr>


</tr>
    <td class="pad-lefta blue-txta">  Enter Your Prescription Numbers</td>

<tr>
    
    
  <td class="pad-lefta blue-txta">1.<input type="text" name="rxnums[]" id="Rxnum1" tabindex="5" ></td>
  <td class="pad-lefta blue-txta">4.<input type="text" name="rxnums[]" id="Rxnum4" tabindex="8" ></td>

<!--  <td rowspan="4" valign="top" class="pad-lefta blue-txta"><img src="$staticimages_http_prefix/sample-prescription.gif" /></td>-->

</tr>
<tr>
    
   
     <td class="pad-lefta blue-txta">2.<input type="text" name="rxnums[]" id="Rxnum2" tabindex="6"></td>
     <td class="pad-lefta blue-txta">5.<input type="text" name="rxnums[]" id="Rxnum5" tabindex="9" ></td>

   </tr>
<tr>
 
      <td class="pad-lefta blue-txta">3.<input type="text" name="rxnums[]" id="Rxnum3" tabindex="7"></td>
      <td class="pad-lefta blue-txta">6.<input type="text" name="rxnums[]" id="Rxnum6" tabindex="10" ></td>

    </tr>

<tr>
<td class="pad-lefta blue-txta"> Note</td>

</tr>

<tr>
  
    
    <td class="pad-lefta blue-txta"> <textarea name="note" id="note" cols="25" rows="5" tabindex="20"></textarea></td>
<td class="pad-lefta blue-txta"><input type="submit" name="submitBtn" id="submitBtn" value="Submit" tabindex="25"></td>

    <td class="pad-lefta blue-txta">&nbsp;</td>
</tr> 




    
<tr>
<td></td>

<td class="pad-lefta blue-txta">&nbsp;</td>

</table>
<!-- Content Area End -->
    </td>
  </tr>
  <tr>
    <td width="100%" class="row3" colspan="2">
    
</form>

    
[[static_footer.html]]