[[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>



<!--********************************************-->

<div id="content">
	<div class="inner-banner">
        <div class="container"><h1 class="blog-title">Custom MAR</h1></div>
     
    </div>
				<div class="container loginpge">
					<!-- Login form -->
                                  <form  name="frm" action="marprint.php" target="_blank" method="post">

						<h3 class="title-divider">
							<span>$patient_name</span>
							<small>Fill in Dates below and  click submit</small>
						</h3>
                                           <div class="form-group">
					  	    <h6>Start Date (yyyy-mm-dd)</h6>
 						      <label class="sr-only">Enter Start Date </label>
						      <input type="text" class="form-control" name="startdate" id="startdate" value="$startd">
					        </div>
                                           <div class="form-group">
					  	    <h6>End Date (yyyy-mm-dd)</h6>
 						      <label class="sr-only">Enter End Date </label>
						      <input type="text" class="form-control" name="enddate" id="enddate" value="$endd">
                                                <input type="hidden" name="patientid" value="$patid"> 
                                                <input type="hidden" name="storeid" value="$storeid">
					        </div>

                      <button type="submit" class="btn btn-primary">Submit</button>

					</form>
					<div class="half-width">
						<img width="368" height="242" class="alignnone size-full wp-image-185" alt="login-img" src="http://suttonrx.wpengine.com/wp-content/uploads/2015/03/login-img.jpg">
                    </div>
					<div class="row-fluid">
						<div class="col-md-6 col-md-offset-3">

                                          <!-- Session Expiry and Login Error START -->
                                             <p>
                                                {$is_expired{<font color="#ff0000">Your session has expired. Please log in again.</font>}}<br>
                                                {$error{<font color="#ff0000">$error</font>}}
                                             </p>
                                          <!-- Session Expiry and Login Error  END -->

							<h4></h4>
							<p></p>
							<ul class="fa-ul list-lg">
							
							</ul>
						</div>
					</div>
				</div>
</div>


<!--********************************************-->




[[static_footer.html]]