[[static_erefill_header.html]]
{$error{$error}} {!$error{
Back to Homes |$loginname | Logout

## Order for:$patient_firstname $patient_lastname

$store

Drug Detail | Status | Select
--- | --- | ---
$profile

### Order Options
Health Professional's Email: Special Instructions Back to Patient List

}} [[static_footer.html]] <>

$store_name

Phone: $store_phone $store_address, $store_city

<> <>

Date: $profile_filldate

$profile_tradename $profile_drugstrength

$profile_genericname $profile_drugstrength

Rx#: $profile_rxnumber

$profile_doctor

Quantity: $profile_fillquantity

Repeats: $profile_repeats

Authorized: $profile_quantityauthorized

Remaining: $profile_quantityremaining

{$orderable{
}} $profile_reason
<> <> $select_item <>