[[static_app_header.html]]


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

<div align="center">
	<table border="0" width="95%" cellspacing="0" cellpadding="0">
		<tr>
			<td width="100%" height="40">
				<div align="right">
					<table border="0" width="98%" cellspacing="0" cellpadding="0">
							<tr>
								<td class="blue-txta"><h1>Confirm your Order</h1></td>
								<td align="right">Welcome <b> $patient_firstname $patient_lastname</b></td>
								<td width="30" align="right"><img border="0" src="$staticimages_http_prefix/security.jpg" width="14" height="16" /></td>
								<td width="45" align="right"><a href="logout.php">Logout</a></td>
							</tr>				
					</table>
				</div>    
			</td>
		</tr>
		

<br>



<tr>
			<td width="100%" class="bluef" height="40">
			<div align="center">
									<table border="0" width="95%" cellspacing="0" cellpadding="1">
											<tr>
												<td class="white-txt"><h3>$store_name</h3></td>
												<td class="white-txt" align="right"><h3>Phone: $store_phone</h3></td>
											</tr>
											<tr>
												<td colspan="2" class="white-txt"><h3>$store_address,  $store_city</h3></td>
											</tr>
									</table>
      </div>
      
      </td>
</tr>



<table border="0" width="95%" cellspacing="0" cellpadding="1">
<tr>	  
<td width="100%" class="left-right top blue-txta" height="30"> <br>
$patient_firstname $patient_lastname {$customers_email{&lt;$customers_email&gt;}}</b><br>
$patient_line1 $patient_line2<br>
$patient_cityname $patient_provincename $patient_postalcode<br><br>
 </td>
</tr>
</table>





<table border="0" width="95%" cellspacing="0" cellpadding="1">
<tr>
<!--	<td align="left" valign="top">{$customers_ispickup{Pickup}}{!$customers_ispickup{Delivery}} Date:</th>
	<td align="left" valign="top">$customers_pickdeldate $customers_pickdeltime</td>-->
</tr>
{$customers_deladdress{
<tr>
	<td class="left-right top blue-txta" align="left" valign="top" width="22%">Delivery Address:</th>
	<td class="left-right top blue-txta" align="left" valign="top">$customers_deladdress</td>
</tr>
}}
{$customers_note{
<tr>
	<td class="left-right bottom blue-txta" align="left" valign="top" width="22%">Comment:</td>
	<td class="left-right bottom blue-txta" align="left" valign="top">$customers_note</td>
</tr>
}}
</table>
<br />

<br />


<table border="0" width="95%" cellspacing="0" cellpadding="1">
          <tr>
            <td class="pad-lefta white-txt bluef white-border" height="25"><b>Rx Number</b></td>
            <td class="pad-lefta white-txt bluef white-border" height="25"><b>Drug Name</b></td>
          </tr>
         
$profiles
</table>

<br>

<TABLE border="0" width="95%" cellspacing="0" cellpadding="1">
<TR>
<TD align="left">
	<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="image" style="border-style: none" src="$staticimages_http_prefix/but-confirm.jpg" value="Confirm" />&nbsp;
	<a href="#" onclick="history.back(1);"><IMG border="0" src="$staticimages_http_prefix/but-cancel.jpg" alt="Cancel" /></a>
	</form>
</TD>
</TR>
</TABLE>
<br>
[[static_footer.html]]

<<profile>>
<tr>
	<td class="left bottom pad-lefta blue-txta" height="25" align="left" valign="top">$profile_rxnumber</td>
	<!--<td class="bodytext" align="left" valign="top">$profile_din</td>-->
	<td class="right bottom pad-lefta blue-txta" height="25" align="left" valign="top">$profile_drugname </td>
	<!--<td class="bodytext" align="left" valign="top"><font color="$rxs_color"><b>$profile_status</b></font></td>-->
</tr>
<</profile>>