[[static_erefill_header.html]]

{$error{<font color="#ff0000">$error</font>}}

<div id="content">
	<div class="container">
		<div class="row-fluid">
			<div class="">
				<div class="pull-right log-section"><span><strong><span class="user-name">$loginname</span></strong>  <a href="logout.php"><span class="icon-in-link"><i class="fa fa-unlock"></i> </span>Logout </a></div>
				<h2 class="title-divider">
				  <span>Confirm <span class="de-em">your order for: $patient_firstname $patient_lastname</span></span>
				</h2>

<!-- Prescription table start -->
						<div class="row">
							<div class="">
								<div class="row-fluid shade">
									<div class="row">
										<div class="col-md-6">
											<p><strong>$store_name</strong><br />
											<p><strong>Phone: $store_phone</strong></p>
											$store_address,  $store_city</p>
										</div>
										<div class="col-md-6"></div>
									</div>
								</div>
								<div class="row-fluid">
									<div class="col-md-12 div-bordered">
										<P><strong>$patient_firstname $patient_lastname </strong><br />
										$patient_line1 $patient_line2<br />
										$patient_cityname $patient_provincename $patient_postalcode <br/>
										<strong>{$customers_email{&lt;$customers_email&gt;}}</strong></p>
									</div>
									<div class="row-fluid div-bordered">
										<div class="col-md-12 div-bordered" >
											<P><strong>Delivery Address:</strong>{$customers_deladdress{ $customers_deladdress}}</P>
											<P><strong>Comment:</strong>{$customers_note{$customers_note}}</P>
										</div>
									</div>
								</div>
							</div>
						</div>
						<!-- Prescription table end -->

						<p>&nbsp;</p>
                                           
						<div class="row">
                                           <div class="">
						 	<div class="row-fluid">
						       	<div class="col-md-12 div-bordered" style="background-color:#C9C9C9;">
  									<table class="footable table demo table-bordered toggle-arrow">
		 	                     			<thead>
				               			   <tr>
						          			<th data-toggle="true" >
											Rx Number
										</th>
										<th data-toggle="true">
											Drug Name
  										</th>
	 								   </tr>
								       </thead>
									<tbody>
									   $profiles
									</tbody>
									</table>
 							  	</div>
							</div>
						 </div>
					      </div>







                                    
					<div class="row">
                                   	<form name="frm" action="$orderrefills_url"  method="post">
		           				<input type="hidden" name="Email" value="$customers_email">
							<input type="hidden" name="SpecialInstructions" value="$customers_note">
							<input type="hidden" name="dte" value="$customers_pickdeldate">
							<input type="hidden" name="dptime" value="$customers_pickdeltime">
							<input type="hidden" name="pdel" value="$customers_pickupdelivery">
							<input type="hidden" name="DeliveryAddress" value="$customers_deladdress">
							<input type="hidden" name="storeid" value="$customers_store">
							<input type="hidden" name="rxid" value="$customers_rxids">
							<input type="hidden" name="nhid" value="$nhid">

      							<div style="margin:10px 5px;">
                                                                                            
    								  <table>
            							     <tr>
                                                              <td>
							               <button type="submit" class="btn btn-primary"><i class="fa fa-check"></i> Confirm
								      </td>
								      <td>
                                                               <a href="javascript:history.go(-1)" class="btn btn-primary"><span class="glyphicon glyphicon-remove" style="display:inline;"></span> Cancel</a>
                                                              </td>
								    </tr>
								</table>

                                                        
							</div>
                                                 

	
						</form>

					
					</div>
				
			</div>
		</div>
	</div>
</div>

[[static_footer.html]]

<<profile>>

<tr>
  <td width="10%">
    <div class="row-fluid">
	
	<div class="col-md-4">
		<p><strong>$profile_rxnumber</p>
	</div>
    </div>
   </td>
   <td>
    <div class="row-fluid">
	
	<div>
		<p><strong>$profile_drugname</p>
	</div>
    </div>
   </td>
</tr>

<</profile>>