[[static_erefill_header.html]]

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


function orderbynumbervalidation()
{
	var ValidChars = "0123456789.";
	var IsNumber=true;
	var Char;
	var telephone = document.frm.telephone.value;
	if(telephone == "")
	{
		alert("Telephone Number must be filled in and match a phone number on file at the store for each prescription");		
		return false;
	} 
	else 
	{
	 for (i = 0; i < telephone.length && IsNumber == true; i++) 
      { 
      Char = telephone.charAt(i); 
      if (ValidChars.indexOf(Char) == -1) 
         {
		   isnumber=false;	 
		   alert("Invalid Characters in Phone Number only use 0123456789");	 
           return false;
         }
      }
	  if (telephone.length!=10)
	  {
		 alert("Invalid Phone Number format shoud be 9999999999 10 digits including areacode ");
		  return false;
	  }
	}
	
	if (validaterxs() == false)
	{
		return false;
	}
		
			
	return true;
	
	
}
function validaterxs()
{
	var j =0;
	var k =0;
	var m =0;
	var txt = "";
	var storeshort ="";
	var pos=-1;
	for(i=0; i<document.forms[0].elements.length;i++)
	{

		if(document.forms[0].elements[i].type == "text")
			{
				if (document.forms[0].elements[i].name == "rxnums[]")
					{
						if (document.forms[0].elements[i].value!="") 
							{
				   			j=j+1;
				   			txt=document.forms[0].elements[i].value;
							pos=txt.indexOf("-");
							if (pos==-1)
							{
				   					k=k+1;
				   			}
							else
							{
							 if (storeshort=="")	
							 {
								 storeshort=txt.substr(pos+1);
							 }
							 if (storeshort!=txt.substr(pos+1))
							 {
								 m=m+1;
							 }
							}
							}
					}
			}
	}
	if (j==0) 
	{
		alert("please fill in at least one prescription number to refill "		);
		return false;
	}
	if (k>=1) 
	{
		alert("missing - Store on at least one prescription "		);
		return false;
	}
	if (m>=1) 
	{
		alert("please order from one store at a time "		);
		return false;
	}
	
	return true;
}





</script>





<!-- Content Area Start -->
<form id="frm" name="frm" method="post" action="orderrefillsbynumber.php" onsubmit="return orderbynumbervalidation()">
      <table border="0" width="100" cellspacing="2" cellpadding="2">

<tr>


<td colspan=3 class="pad-lefta blue-txta"><h1>Welcome to e-Refill</h1><br /></td>


</tr>

<tr>
      
     <td class="pad-lefta blue-txta">Your Phone</td>
      <td class="pad-lefta blue-txta">  <input type="text" name="telephone" id="telephone" /><br>example: 4163537219</td>
      </tr>

<tr>
      
     <td class="pad-lefta blue-txta">Pharmacy Phone</td>
      <td class="pad-lefta blue-txta">  <input type="text" name="telephonepharm" id="telephonepharm" /><br>example: 4168838835</td>
      </tr>




<tr>
    
    
    <td class="pad-lefta blue-txta"> Rx1 </td>
    <td class="pad-lefta blue-txta">  <input type="text" name="rxnums[]" id="Rxnum1" tabindex="1" /><br>example: 1234567-LON</td>
    <td rowspan="4" valign="top" class="pad-lefta blue-txta"><img src="$staticimages_http_prefix/sample-prescription.gif" /></td>
</tr>
<tr>
    
     <td class="pad-lefta blue-txta">  Rx2 </td>
     <td class="pad-lefta blue-txta">   <input type="text" name="rxnums[]" id="Rxnum2" /></td>
     </tr>
<tr>
   <td class="pad-lefta blue-txta"> Rx3</td>
      <td class="pad-lefta blue-txta">  <input type="text" name="rxnums[]" id="Rxnum3" /></td>
      </tr>
      
   <tr>
   <td class="pad-lefta blue-txta"> Rx4</td>
      <td class="pad-lefta blue-txta">  <input type="text" name="rxnums[]" id="Rxnum4" /></td>
   </tr>
   <tr>
   <td class="pad-lefta blue-txta"> Email</td>
      <td class="pad-lefta blue-txta">  <input type="text" name="email" id="email" /></td>
   </tr>
   
<tr>
<td class="pad-lefta blue-txta"> Refill Reminder </td>
<td class="pad-lefta blue-txta"><input type="checkbox" class="check" name="refillreminder" value="Y" checked="checked" /> </td>
    

</tr>
<tr>
  
    <td class="pad-lefta blue-txta"> Note</td>
    <td class="pad-lefta blue-txta"> <textarea name="note" id="note" cols="25" rows="5"></textarea></td>
    <td class="pad-lefta blue-txta">&nbsp;</td>
</tr>     
<tr>
<td></td>
<td class="pad-lefta blue-txta"><input type="submit" name="submitBtn" id="submitBtn" value="Submit" /></td>

<td class="pad-lefta blue-txta">&nbsp;</td>

</table>
<!-- Content Area End -->
    </td>
  </tr>
  <tr>
    <td width="100%" class="row3" colspan="2">
    
</form>

    
[[static_footer.html]]