<?php
include_once("config.php");
$formsubmit = $_REQUEST['formsubmit']; 
$firstname = $_REQUEST['firstname']; 
$lastname = $_REQUEST['lastname']; 
$birthdate = $_REQUEST['birthdate']; 
$address = $_REQUEST['address']; 
$email = $_REQUEST['email'];
$phonenumber = $_REQUEST['phonenumber']; 
$healthcard = $_REQUEST['qeleven']; 
$memberid = $_REQUEST['qtwelve']; 
$pharmacyname = $_REQUEST['qeight']; 
$pharmacylocation = $_REQUEST['qten']; 
$pharmacyphone = $_REQUEST['qnine']; 

$choose = $_REQUEST['qthirteen'];
if($choose == 'COMPLETE'){
    $prescriptions = 'COMPLETE FILE TRANSFER'; 
}else{
$prescription1 = $_REQUEST['qone']; 
$prescription2 = $_REQUEST['qtwo']; 
$prescription3 = $_REQUEST['qthree']; 
$prescription4 = $_REQUEST['qfour']; 
$prescription5 = $_REQUEST['qfive']; 
$prescription6 = $_REQUEST['qsix']; 
$prescription7 = $_REQUEST['qtwentysix']; 
$prescription8 = $_REQUEST['qtwentyseven']; 
$prescription9 = $_REQUEST['qtwentyeight']; 
$prescription10 = $_REQUEST['qtwentynine'];
$prescriptions = $prescription1.','.$prescripton2.','.$prescription3.','.$prescription4.','.$prescription5.','.$prescription6.','.$prescription7.','.$prescription8.','.$prescription9.','.$prescription10;//CONCATENATE LIST; 

}

$comments = $_REQUEST['qseven']; 
$datesigned = $_REQUEST['datesigned']; 



$fillinstructions = '';//CONCATENATE FILL INSTR
/*
'q16'=>'Alberta Health Number'.'|'.$qeleven,
'q17'=>'ARTA Membership Number'.'|'.$qtwelve,
'q18'=>'Pharmacy Name'.'|'.$qeight,
'q19'=>'Pharmacy Location'.'|'.$qten,
'q20'=>'Pharmacy Phone Number'.'|'.$qnine,
'q21'=>'Choose'.'|'.$qthirteen,
'q22'=>'Fill Instructions (If Complete Prescription File chosen)'.'|'.$qfourteen,
'q23'=>'Prescription 1 (If Only Certain Prescriptions)'.'|'.$qone,
'q24'=>'Fill Instructions'.'|'.$qfifteen,
'q25'=>'Prescription 2'.'|'.$qtwo,
'q26'=>'Fill Instructions'.'|'.$qsixteen,
'q27'=>'Prescription 3'.'|'.$qthree,
'q28'=>'Fill Instructions'.'|'.$qseventeen,
'q29'=>'Prescription 4'.'|'.$qfour,
'q30'=>'Fill Instructions'.'|'.$qeighteen,
'q31'=>'Prescription 5'.'|'.$qfive,
'q32'=>'Fill Instructions'.'|'.$qnineteen,
'q33'=>'Prescription 6'.'|'.$qsix,
'q34'=>'Fill Instructions'.'|'.$qtwenty,
'q35'=>'Prescription 7'.'|'.$qtwentysix,
'q36'=>'Fill Instructions'.'|'.$qtwentytwo,
'q37'=>'Prescription 8'.'|'.$qtwentyseven,
'q38'=>'Fill Instructions'.'|'.$qtwentythree,
'q39'=>'Prescription 9'.'|'.$qtwentyeight,
'q40'=>'Fill Instructions'.'|'.$qtwentyfour,
'q41'=>'Prescription 10'.'|'.$qtwentynine,
'q42'=>'Fill Instructions'.'|'.$qtwentyfive,
'q43'=>'Comments'.'|'.$qseven,
'q45'=>'Date signed'.'|'.$datesigned,

*/


if($formsubmit == true){

}else{
$template = new index_page("template_0010_rxtransferform2.html");
$template->erefill=$erefill;
$template->advanced=$advanced;
$template->grouplogin=$grouplogin;
$template->delivery=$delivery;
$template->curbside=$curbside;
$template->storecombo=$storecombo;
$template->refilltitle=$refilltitle;
$template->refillnote=$refillnote;
$template->refillmessage=$refillmessage;
$template->show();
}
?>