[[static_header.html]]
<tr>
	[[static_sidebar_pharmacy.html]]
		                      <td class="row2" id="content-area">
                            <!-- Content Area Start -->
							
							
							<div id="coupons-page">
							<h2 class="blue-txta">24/7 Rx Refills </h2>
							<p class="blue-txta">Rx Refills is a quick Way to 
							Order your Rxs. Simply type in your phone number and 
							prescription number(s). Click Submit and you are 
							done. No login required. Fast, simple and easy.</p>
							<table border="0" cellSpacing="2" cellPadding="2" width="100">
								<tr>
									<td class="pad-lefta blue-txta" colSpan="3">&nbsp;</td>
								</tr>
								<tr>
									<td class="pad-lefta blue-txta">Phone</td>
									<td class="pad-lefta blue-txta">
									<input id="telephone0" name="telephone0"><br>
									example: 4163537219</td>
								</tr>
								<tr>
									<td class="pad-lefta blue-txta">Rx1 </td>
									<td class="pad-lefta blue-txta">
									<input id="Rxnum5" tabIndex="1" name="rxnums[]0"><br>
									example: 1234567-LON</td>
									<td class="pad-lefta blue-txta" vAlign="top" rowSpan="4">
									<img border="0" src="$staticimages_http_prefix/sample-prescription.gif"></td>
								</tr>
								<tr>
									<td class="pad-lefta blue-txta">Rx2 </td>
									<td class="pad-lefta blue-txta">
									<input id="Rxnum6" name="rxnums[]1"></td>
								</tr>
								<tr>
									<td class="pad-lefta blue-txta">Rx3</td>
									<td class="pad-lefta blue-txta">
									<input id="Rxnum7" name="rxnums[]2"></td>
								</tr>
								<tr>
									<td class="pad-lefta blue-txta">Rx4</td>
									<td class="pad-lefta blue-txta">
									<input id="Rxnum4" name="rxnums[]3"></td>
								</tr>
								<tr>
									<td class="pad-lefta blue-txta">Email</td>
									<td class="pad-lefta blue-txta">
									<input id="email" name="email"></td>
								</tr>
								<!--   <tr>
<td class="pad-lefta blue-txta"> Refill Reminder </td>
<td class="pad-lefta blue-txta"><input type="checkbox" class="check" name="refillreminder" value="Y" checked="checked" /> </td>
    

</tr> -->
								<tr>
									<td class="pad-lefta blue-txta">Note</td>
									<td class="pad-lefta blue-txta">
									<textarea id="note0" rows="5" cols="25" name="note0"></textarea></td>
									<td class="pad-lefta blue-txta">&nbsp;</td>
								</tr>
								<tr>
									<td>&nbsp;</td>
									<td class="pad-lefta blue-txta">
									<input id="submitBtn0" value="Submit" type="submit" name="submitBtn0"></td>
									<td class="pad-lefta blue-txta">&nbsp;</td>
								</tr>
							</table>
							
							</div>
                        </td>

		
</tr>
[[static_footer.html]]