[[static_erefill_header.html]]

<!-- Content Area Start -->
<form id="frm" name="frm" method="post" action="marprint.php">
      <table border="0" width="100" cellspacing="2" cellpadding="2">


<tr>
<!-- 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 -->

</tr>
<tr>


<td colspan=3 class="pad-lefta blue-txta"><h1>MAR PRINT <br /><br  /> </h1><br /></td>


</tr>
<td colspan=3 class="pad-lefta blue-txta">Link: <h1> $rx_link </h1> </td>

<tr>
<td colspan=3 class="pad-lefta blue-txta">Patient Name: <h1> $patient_name </h1> </td>

</tr>
<tr>
<td colspan=3 > <input type="hidden" name="patientid" value="$patid" tabindex"2"> </td>

</tr>
<tr>
<td colspan=3 > <input type="hidden" name="storeid" value="$storeid" tabindex"2"> </td>

</tr>

<tr>
<td class="pad-lefta blue-txta">Start Date (yyyy-mm-dd)</td>
<td class="pad-lefta blue-txta"> End Date(yyyy-mm-dd) </td>
</tr>

  <td class="pad-lefta blue-txta">  <input type="text" name="startdate" id="startdate" tabindex="2"> </td>
   
  <td class="pad-lefta blue-txta">  <input type="text" name="enddate" id="enddate" tabindex="3"> </td>
      </tr>


      

<tr>
  
    
<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]]