Fairview Pharmacy - Online Prescripton Order Form

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font-weight: lighter;">< <a href="https://web.archive.org/web/20120524050559/http://www.fairview.org/Pharmacy/index.htm">Pharmacy</a></div>  <h2 style="color:#315584;">Prescription Refills</h2>   <div class="sidebarNav sidebarNavLinks"> <ul> <li><a href="https://web.archive.org/web/20120524050559/https://sslforms.fairview.org/rxtransfer.asp" class="Leftnav_table">Prescription Transfers</a></li> <li><a href="https://web.archive.org/web/20120524050559/http://www.fairview.org/Pharmacy/Ourpharmacies/index.htm" class="Leftnav_table">Pharmacy Locations</a></li> <li><a href="https://web.archive.org/web/20120524050559/http://www.fairview.org/Pharmacy/Compoundingpharmacy/index.htm" class="Leftnav_table">Compounding Pharmacy</a></li> <li><a href="https://web.archive.org/web/20120524050559/http://www.fairview.org/Pharmacy/Clinicaltrials/index.htm" class="Leftnav_table">Clinical Trials</a></li> <li><a href="https://web.archive.org/web/20120524050559/http://www.fairview.org/Pharmacy/Infusionservices/index.htm" class="Leftnav_table">Infusion Services</a></li> <li><a href="https://web.archive.org/web/20120524050559/http://www.fairview.org/Pharmacy/Mailservice/index.htm" class="Leftnav_table">Mail Service</a></li> <li><a href="https://web.archive.org/web/20120524050559/http://www.fairview.org/Pharmacy/MedicationTherapyManagement/index.htm" class="Leftnav_table">Medication Therapy Management</a></li> <li><a href="https://web.archive.org/web/20120524050559/http://www.fairview.org/Pharmacy/Oncologypharmacy/index.htm" class="Leftnav_table">Oncology Pharmacy</a></li> <li><a href="https://web.archive.org/web/20120524050559/http://www.fairview.org/Pharmacy/Specialtypharmacy/Fertilityprogram/index.htm" class="Leftnav_table">Reproductive Medicine</a></li> <li><a href="https://web.archive.org/web/20120524050559/http://www.fairview.org/Pharmacy/Specialtypharmacy/index.htm" class="Leftnav_table">Specialty Pharmacy</a></li> <li><a href="https://web.archive.org/web/20120524050559/http://www.fairview.org/Pharmacy/Ourpharmacies/Contactus/index.htm" class="Leftnav_table">Contact us</a></li> </ul> </div> <div class="txtBox">   </div> </div>  </div>   <div id="content" style="float:left; width:685px; margin:0; border:0; padding:5px 15px; display:inline;">  <br clear="all"/>  <div style="MARGIN-LEFT: 25px; LINE-HEIGHT: 1.9em; MARGIN-RIGHT: 12px"> <span class="title" id="hospitalblue">Prescription Refills</span> <span class="subtitle"><br> Order your prescriptions online <br/> </span><img height="7" alt="" src="https://web.archive.org/web/20120524050559im_/https://sslforms.fairview.org/images/nav/gray_spacer.gif" width="481" vspace="11" border="0"/><br/></div> <div style="MARGIN-LEFT: 25px; LINE-HEIGHT: 1.4em; MARGIN-RIGHT: 12px">  <style type="text/css">  </style>   <script language="JavaScript" type="text/JavaScript" src="/web/20120524050559js_/https://sslforms.fairview.org/refill_validation.js?s=1337817960"></script> <script language="javascript" type="text/javascript" src="/web/20120524050559js_/https://sslforms.fairview.org/refill_pharmacy_logic2.js?s=1337817960"></script> <p align="left" class="fvMainBody"> <strong>Please Note:</strong> If a prescription in this order lacks remaining refills or has expired, processing may be delayed as we obtain a renewal from your physician. If your prescription requires refrigeration, we will need to contact you regarding a delivery date. </p> <form action="refill_handler.asp" method="post" name="refillOrderForm" id="refillOrderForm" onsubmit="return validate()"> <input name="PharmacyInternalName" type="hidden" value=""> <input name="PharmacyExternalName" type="hidden" value=""> <input name="PharmacyFaxNumber" type="hidden" value=""> <input name="PharmacyDashFaxNumber" type="hidden" value=""> <input name="OrderID" type="hidden" value=""> <input name="PharmacyURL" type="hidden" value=""> <table align="center" cellpadding="5" cellspacing="0" style="border: 1px solid black; width:90%"> <tbody> <tr align="center" valign="middle"> <th colspan="3" bgcolor="#F4DD7F"><div class="fvSubHead">Refill Order </div></th> </tr> <tr align="center"> <th colspan="3" valign="top" style="border: 1px solid #ececec; background: #fffded; padding:3px;"><div id="step1"><p class="subtitle2" style="padding:0px; margin-top:0px; color:#000000;">Step 1</p> </div> <p class="subtitle3">How many prescriptions do you wish to refill?<br> <span style="font-size:smaller;">(15 maximum)</span><br> <input name="numOfRx" id="numOfRx" onchange="numberOfRefills(this.value)" onkeyup="numberOfRefills(this.value)" onblur="numberOfRefills(this.value)" size="4" maxlength="3"> </p> <p class="subtitle3">Which Fairview pharmacy would you like to refill these at?<br> <select name="pharmacy" default size="1" onchange="getPharmacyInfo(this.value)" onblur="getPharmacyInfo(this.value)"> <option selected value="Select Pharmacy">Select Pharmacy</option> <option value="282">Mail Service</option> <option value="49">Andover</option> <option value="42">Apple Valley</option> <option value="52">Blaine</option> <option value="38">Bloomington</option> <option value="51">Brooklyn Park</option> <option value="16">Burnsville - Ridgeview</option> <option value="48">Columbia Heights</option> <option value="26">Eagan</option> <option value="97">Eden Prairie</option> <option value="14">Edina - Physicians Building</option> <option value="13">Edina - Southdale Medical Building</option> <option value="18">Elk River</option> <option value="34">Hugo</option> <option value="33">Lino Lakes</option> <option value="47">Maple Grove</option> <option value="23">Milaca</option> <option value="10">Minneapolis - Hiawatha</option> <option value="20">Minneapolis - Northeast</option> <option value="12">Minneapolis - Riverside</option> <option value="45">Minneapolis - Smileys Clinic</option> <option value="40">Minneapolis - Univ. Villiage</option> <option value="50">New Brighton</option> <option value="17">Princeton</option> <option value="54">Prior Lake</option> <option value="25">Red Wing</option> <option value="29">Rush City</option> <option value="281">Specialty</option> <option value="11">St. Paul - Highland Park</option> <option value="27">University Discharge</option> <option value="19">University Outpatient</option> <option value="21">Wyoming</option> <option value="22">Zimmerman</option> </select> </p></th> </tr> <tbody style="display:none;" id="refillFormArea"> <tr align="center" valign="middle" style="background-color: #F4DD7F;"> <th style="border: 1px solid #ececec; padding:3px;"><p class="fvMainBody">Your Information</p></th> <th style="border: 1px solid #ececec; padding:3px;"><p class="fvMainBody">Prescription Numbers</p></th> <th style="border: 1px solid #ececec; padding:3px;"><p class="fvMainBody">Delivery Method</p></th> </tr> <tr> <td width="30%" align="left" valign="top" style="border-right: 1px solid #ececec;"><div id="step2" style="text-align:center;"><p class="subtitle2" style="padding:0px; margin-top:0px; color:#000000;">Step 2</p> </div> <p class="fvMainBody"><span class="subtitle3">First Name:</span><br> <input name="firstName" id="firstName" size="20" maxlength="20"/> </p> <p class="fvMainBody"> <span class="subtitle3">Last Name:</span><br> <input name="lastName" type="text" id="lastName" size="20" maxlength="50"/> </p> <p class="fvMainBody"> <span class="subtitle3">Phone Number:</span><br> <input name="phoneNumber" id="phoneNumber" size="20" maxlength="15"/> </p> <p class="fvMainBody"> <span class="subtitle3">Email Address</span><br> <input name="email" id="email" size="20" maxlength="50"/> </p> <p class="fvMainBody"><span class="subtitle3">Confirm Email Address</span><br> <input name="confirmEmail" type="text" id="confirmEmail" size="20" maxlength="50"/> </p> <p class="fvMainBody"><span class="subtitle3">Comments</span><br> <textarea name="comments" cols="15" rows="5" id="comments" wrap="hard"></textarea> </p></td> <td width="30%" align="left" valign="top" style="border-right: 1px solid #ececec;"><div id="step3" style="text-align:center"><p class="subtitle2" style="padding:0px; margin-top:0px; color:#000000;">Step 3</p> </div> <p class="fvMainBody">Please enter the prescription number(s) you want to refill below. </p> <p class="fvMainBody"><strong>If you don't know your prescription number, please:</strong></p> <p class="fvMainBody">- Enter <strong>98-7654321</strong> in as your prescription number..</p> <p class="fvMainBody">- And list the drug name in the comments section</p> <div id="orderNumbers">   </div> </td> <td width="30%" align="left" valign="top" style="border-right: 1px solid #ececec;"><div id="step4" style="text-align:center"><p class="subtitle2" style="padding:0px; margin-top:0px; color:#000000;">Step 4</p> </div> <p class="fvMainBody" id="pickUp"><span class="subtitle3">Choose a delivery method:</span><br> <span id="twoDays"><input name="pickUp" type="radio" id="twoDayButton" onclick="creditCard('false')" value="in 2 days" checked> Pick up in 2 or more days<br></span> <span id="nextDay"><input name="pickUp" type="radio" id="nextDayButton" onclick="creditCard('false')" value="next day"> Pick up next day <br></span> <span id="today"><input name="pickUp" type="radio" id="todayButton" onclick="creditCard('false')" value="at store today"> Pick up at store today<br></span> <span id="mail"><input name="pickUp" type="radio" id="mailOrderButton" onclick="creditCard('true')" value="mail"> Delivery by mail (free shipping)</span> </p> <div id="creditCard" style="display: none;"> <p class="fvMainBody"> If you have an existing form of payment on file with us, please enter it below. If not or you are unsure, leave the blanks below empty and we will call during pharmacy hours to confirm payment details. </p> <p class="fvMainBody"><span class="subtitle3">Credit Card Type</span><br> <select name="creditCardType" size="1" id="creditCardType"> <option value=""> </option> <option value="Visa">Visa</option> <option value="Master Card">Master Card</option> <option value="Amex">Amex</option> <option value="Discover">Discover</option> </select> </p> <p class="fvMainBody"> <span class="subtitle3">Card Number<br/>(Last 4 Digits)</span> <br> <input name="creditCardNum" type="text" id="creditCardNum" size="4" maxlength="4"/></p> <p class="fvMainBody"><span class="subtitle3">Card Expiration Date</span><br> <select name="creditCardExpirationMonth" size="1" id="creditCardExpirationMonth"> <option value=""> </option> <option value="01">01</option> <option value="02">02</option> <option value="03">03</option> <option value="04">04</option> <option value="05">05</option> <option value="06">06</option> <option value="07">07</option> <option value="08">08</option> <option value="09">09</option> <option value="10">10</option> <option value="11">11</option> <option value="12">12</option> </select> <select name="creditCardExpirationYear" size="1" id="creditCardExpirationYear"> <option value=""> </option> <script language="JavaScript" type="text/javascript"> /* <![CDATA[ */ document.write(getExpirationYears(7)); /* ]]> */ </script> </select> </p> </div> <div id="pharmacyHours" style="display:none;"> The pharmacy hours would be here </div>  <div id="formButtons" style="margin-top:15px;"><input name="submit" type="submit" id="submit" value="Submit Refill Order"/>      </div> </td> </tr> <tr align="center" valign="middle" style="background-color:#E5E5E5;"> <th colspan="5"> </th> </tr> </tbody> </table> </form> <script language="JavaScript" type="text/JavaScript"> //automatically reset the form as it's loaded each time document.refillOrderForm.reset(); </script> <noscript> <p class="fvMainBody">This page uses Javascript to provide you functionality and to improve your experience in using the order form. You have either disabled the Javascript options for your browser or you browser does not support Javascript. 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Fairview Pharmacy - Online Prescripton Order Form