[[static_erefill_header.html]] {$error{$error}}
$loginname Logout

## Confirm your order for: $patient_firstname $patient_lastname

$store_name

Phone: $store_phone

$store_address, $store_city

$patient_firstname $patient_lastname
$patient_line1 $patient_line2
$patient_cityname $patient_provincename $patient_postalcode
{$customers_email{<$customers_email>}}

Delivery Address:{$customers_deladdress{ $customers_deladdress}}

Comment:{$customers_note{$customers_note}}

Rx Number | Drug Name
--- | ---
$profiles

| Cancel

[[static_footer.html]] <>

$profile_rxnumber

$profile_drugname

<>