[[static_app_header.html]]

<script language="JavaScript" type="text/JavaScript">
	


function OrderValidation()
{
	if (c1() == false)
		return false;
		
	
	
	<!-- var email = document.frm.Email.value;-->
<!--	if(validate_email(document.frm.Email,"invalid email") == false)-->
<!--		return false; -->
		
	
		
	return true;
	
	
}
function c1()
{
	for(i=0; i<document.forms[0].elements.length;i++)
	{
		if(document.forms[0].elements[i].type == "checkbox")
		{
			if (document.forms[0].elements[i].checked == true)
				return true;
		}
	}
	alert("please check at least one to refill ");
	return false;
}


function validate_email(field,alerttxt)
{
with (field)
{
apos=value.indexOf("@")
dotpos=value.lastIndexOf(".")
if (apos<1||dotpos-apos<2) 
  {alert(alerttxt);return false}
else {return true}
}
}


</script>


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

{!$error{



<div id="content">
	<div class="container">
		<div class="row-fluid">
			<div class="">
				<div class="pull-right log-section"><span>Welcome <strong><span class="user-name">$patient_firstname $patient_lastname</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>My <span class="de-em">Pharmacies</span></span>
				</h2>
				

                            <form name="frm" action="$orderrefills_confirmation_url"  method="post" onsubmit="return OrderValidation()">


				 
					
					
						<!-- Prescription table start -->
				
						<div class="row-fluid">
							<div class="">
								<div class="row-fluid shade">

									<div class="row">
										<div class="col-md-6">
                                                                             $store
											
										</div>
										<div class="col-md-6">
											
										</div>
									</div>
								</div>
								<table class="footable table demo table-bordered toggle-arrow">
									<thead>
										<tr>
											<th data-toggle="true" >
												Drug Detail
											</th>
											<th data-hide="phone" class="col-status">
												Status
											</th>
											<th class="col-select">
												Select
											</th>
										</tr>
									</thead>
									<tbody>
										$profile
									</tbody>
								</table>
							</div>
						</div>
						<!-- Prescription table end -->
						<div class="row-fluid">
							<div class="col-md-12">
								<div class="row-fluid">
									<div class="col-md-6 col-md-offset-3">
										<table class="table table-bordered">
											<tr>
												<td>
													<h3 class="text-center">Order Options</h3>
												</td>
											</tr>
											<tr>
												<td>
													
														<div class="form-group">
															<label for="field1">*Delivery/Pickup</label>
															<select class="form-control" name="pdel">
															  <option value="P">Pickup</option>
															  <option value="D">Home Delivery</option>
															</select>
														</div>
														<div class="form-group">
															<label for="field2" class="sr-only">Email</label>
															<input type="text" name="Email" placeholder="Email" id="field2" class="form-control">
														</div>
														<div class="form-group">
															<label for="field3" class="sr-only">Delivery Address</label>
															<input type="text" name="DeliveryAddress" placeholder="Delivery Address" id="field3" class="form-control">
														</div>
														<div class="form-group">
															<label for="field4" class="sr-only">Special Instructions</label>
															<input type="text" name="SpecialInstructions" placeholder="Special Instructions" id="field4" class="form-control">
														</div>
                                                                                                  <div class="text-center"><button type="submit" class="btn btn-primary"><i class="fa fa-arrow-right"></i> Order Refill</a></div>


														<!-- <div class="text-center"><a href="orderrefills-confirmation.php" class="btn btn-primary"><i class="fa fa-arrow-right"></i> Order Refill</a></div>
                                                                                                         <button type="submit" class="btn btn-primary">Order Refill</button>-->

													
												</td>
											</tr>
										</table>
									</div>
								</div>
							</div>
						</div>
					  
				
				</form>
			</div>
		</div>
	</div>
</div>



}}

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









    




[[static_footer.html]]

<<store>> 

<!--*********************-->
<p><strong>$store_name</strong><br />
<p><strong>Phone: $store_phone</strong></p>
$store_address,  $store_city</p>
<!--*********************-->

<input class="flat" size="10" readonly="true" type="hidden" name="storeid" value="$store_storeidentifier" />
<input class="flat" size="10" readonly="true" type="hidden" name="nhid" value="$nhid" />
<input class="flat" size="10" readonly="true" type="hidden" name="patientid" value="$patientid" />


<</store>>


<<profile>> 


<!-- ******************************* -->
<tr>
  <td>
    <div class="row-fluid">
	<div class="col-md-4">
	  <div class="text-center">
	      <img src="$profile_drugpic" width="82" height="62" />
             
         </div>
	</div>
	<div class="col-md-8">
       	<p class="text-primary">Date: $profile_filldate</p>
		<p><strong>$profile_tradename $profile_drugstrength</strong></p>
		<p>$profile_genericname &nbsp; $profile_drugstrength</p>
		<p><strong>Rx#: $profile_rxnumber</strong></p>
		<p>$profile_doctor</p>
	</div>
    </div>
   </td>
   <td class="text-center">
	<div class="row-fluid">
	<span><img src="$profile_stateimage" /></span>
		</div>
			<p><strong>Quantity: $profile_fillquantity</strong></p>
			<p><strong>Repeats: $profile_repeats</strong></p>
        		<p>Authorized: $profile_quantityauthorized</p>
			<p>Remaining: $profile_quantityremaining</p>
   </td>
  <td class="text-center">
      <div>{$orderable{  <input type="checkbox" class="check" name="rxid[]" value="$profile_rxid"><br><br>}}
          <font color="red"> $profile_reason 
          </font>
      </div>
  </td>




</tr>
<!-- ******************************* -->


      
 
<</profile>>


<<date_select>> 
<option>$select_item 
<</date_select>>