Fairview Pharmacy - Online Prescripton Transfer Form

<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN" "http://www.w3c.org/TR/1999/REC-html401-19991224/loose.dtd">  <html xmlns="http://www.w3.org/1999/xhtml"> <head><script type="text/javascript" src="/_static/js/bundle-playback.js?v=HxkREWBo" charset="utf-8"></script> <script type="text/javascript" src="/_static/js/wombat.js?v=txqj7nKC" charset="utf-8"></script> <script>window.RufflePlayer=window.RufflePlayer||{};window.RufflePlayer.config={"autoplay":"on","unmuteOverlay":"hidden"};</script> <script type="text/javascript" src="/_static/js/ruffle/ruffle.js"></script> <script type="text/javascript"> __wm.init("https://web.archive.org/web"); __wm.wombat("https://sslforms.fairview.org/rxtransfer.asp","20120524050041","https://web.archive.org/","web","/_static/", "1337835641"); </script> <link rel="stylesheet" type="text/css" href="/_static/css/banner-styles.css?v=S1zqJCYt" /> <link rel="stylesheet" type="text/css" href="/_static/css/iconochive.css?v=3PDvdIFv" />  <meta http-equiv="Content-Type" content="text/html; charset=UTF-8"/> <title>Fairview Pharmacy - Online Prescripton Transfer Form</title>  <link href="/web/20120524050041cs_/https://sslforms.fairview.org/fv/groups/ssadminview/documents/web_assets/fv_style.css" rel="stylesheet" type="text/css"/> <link href="/web/20120524050041cs_/https://sslforms.fairview.org/fv/groups/ssadminview/documents/web_assets/fv_submenus.css" rel="stylesheet" type="text/css"/> <link href="/web/20120524050041cs_/https://sslforms.fairview.org/fv/groups/ssadminview/documents/web_assets/fv_structure.css" rel="stylesheet" type="text/css"/> <link href="/web/20120524050041cs_/https://sslforms.fairview.org/fv/groups/ssadminview/documents/web_assets/fv_left-nav.css" rel="stylesheet" type="text/css"/> <link href="/web/20120524050041cs_/https://sslforms.fairview.org/fv/groups/ssadminview/documents/web_assets/fv_printingcss.css" rel="stylesheet" type="text/css" media="print"/>  <link href="/web/20120524050041cs_/https://sslforms.fairview.org/2/css/fv_pharm.css" rel="stylesheet" type="text/css"/> <link href="/web/20120524050041cs_/https://sslforms.fairview.org/2/css/fv_subtabs-steps.css" rel="stylesheet" type="text/css"/> <link href="/web/20120524050041cs_/https://sslforms.fairview.org/2/css/fv_original_c_093839.css" type="text/css" rel="StyleSheet"/>     <script type="text/javascript" src="/web/20120524050041js_/https://sslforms.fairview.org/fv/groups/ssadminview/documents/web_assets/fv_jquery_library.js"></script> <script type="text/javascript" src="/web/20120524050041js_/https://sslforms.fairview.org/fv/groups/ssadminview/documents/web_assets/fv_custom_functions.js"></script> <script type="text/javascript" src="/web/20120524050041js_/https://sslforms.fairview.org/fv/groups/ssadminview/documents/web_assets/fv_idtabs.js"></script>   <script type="text/javascript"> var gaJsHost = (("https:" == document.location.protocol) ? "https://web.archive.org/web/20120524050041/https://ssl." : "https://web.archive.org/web/20120524050041/http://www."); document.write(unescape("%3Cscript src='" + gaJsHost + "google-analytics.com/ga.js' type='text/javascript'%3E%3C/script%3E")); </script>  <style type="text/css"> .stepNumber { font-size:larger; font-weight:bold; color:#669999; text-align:center; width:auto; } .alert { margin:10px; padding:10px; border:solid 1px #999; background-color:#eee; font-weight:bold; } </style>  </head> <body class="full"> <div id="mainContainer">    <div id="headerfix"> </div> <div id="navHdrBGND"> <div id="navHdrContainer" class="navHdrContainerBGND">   <div id="hospitals_subMenu" class="dropDNmenuB menuTopPosA" style="display:none"> <div class="menuTopB png"></div> <div class="menuContentB"> <div id="Menu1"></div> </div> <div class="menuBottomB png"></div> </div>   <div id="clinics_subMenu" class="dropDNmenuB menuTopPosA" style="display:none"> <div class="menuTopB png"></div> <div class="menuContentB"> <div id="Menu2"></div> </div> <div class="menuBottomB png"></div> </div>   <div id="docProviders_subMenu" class="dropDNmenuB menuTopPosA" style="display:none"> <div class="menuTopB png"></div> <div class="menuContentB"> <div id="Menu3"></div> </div> <div class="menuBottomB png"></div> </div>   <div id="specialties_subMenu" class="dropDNmenuA menuTopPosA" style="display:none"> <div class="menuTopA png"></div> <div class="menuContentA"> <div id="Menu4"></div> </div> <div class="menuBottomA png"></div> </div>   <div id="healthLib_subMenu" class="dropDNmenuA menuTopPosA" style="display:none"> <div class="menuTopA png"></div> <div class="menuContentA"> <div id="Menu5"></div> </div> <div class="menuBottomA png"></div> </div>   <div id="about_subMenu" class="dropDNmenuB menuTopPosA" style="display:none"> <div class="menuTopB png"></div> <div class="menuContentB"> <div id="Menu6"></div> </div> <div class="menuBottomB png"></div> </div>    <div id="fairviewLogo"><a href="https://web.archive.org/web/20120524050041/http://www.fairview.org/index.htm"><img src="/web/20120524050041im_/https://sslforms.fairview.org/fv/groups/internet/documents/web_assets/fv_logo1.gif" alt="Fairview Health Services" style="border:0px; width:182px; height:32px;"/></a></div>  <div class="assistTools"> <div class="liveSupportBTN" style="float:left"><a href="https://web.archive.org/web/20120524050041/https://www.fairview.org:8089/ci/index.jsp?loc=defaultfv"><img src="/web/20120524050041im_/https://sslforms.fairview.org/fv/groups/internet/documents/web_assets/fv_live-help-btn.gif" alt="Live Support" style="border:0px; width:63px; height:27px;" id="liveSupportBTN"/></a></div> <div class="clear"></div> </div>  <div id="utilityNav"> <div id="Menu9"></div> <div class="clear"></div> </div>   <div id="mainNav"> <div id="Menu10"></div> <div class="clear"></div> </div>   <form action="https://web.archive.org/web/20120524050041/http://gsa.fairview.org/search" method="get"> <div id="hdrSearch"> <div class="searchFieldBox" style="float:left"> <input name="q" id="ssUserText" type="text" class="search_inputField" value="Site Search" onfocus="clearDefault(this)"/> </div> <div id="submit-btn"> <input class="png" type="image" src="/web/20120524050041im_/https://sslforms.fairview.org/fv/groups/internet/documents/web_assets/fv_search-btn.png"/> <input type="hidden" name="site" value="www-fairview-org"/> <input type="hidden" name="client" value="fairview-org_frontend"/> <input type="hidden" name="proxystylesheet" value="fairview-org_frontend"/> </div> <div class="clear"></div> </div> </form>   <div id="dropDnLayer" class="dropDnLayerPosA"> <div id="dropDnContainer"> <div id="dropDnContainer-bg"> <div id="dropDNContent-wrapper"> <div id="dropDnContent" class="blueLinks"> <div id="Menu11"></div> <div class="clear"></div> </div> </div> </div> <div id="dropDnContainer-btm"><img class="png" src="/web/20120524050041im_/https://sslforms.fairview.org/fv/groups/internet/documents/web_assets/fv_drop-bottom-bg.png" style="border:0px; width:982px; height:38px;" alt=""/></div> </div> <div id="healthToolsTab"><img class="png" src="/web/20120524050041im_/https://sslforms.fairview.org/fv/groups/internet/documents/web_assets/fv_healthtools_tab.png" alt="My Health Tools" style="border:0px; width:157px; height:22px;"/></div> </div> </div> </div> <script type="text/javascript"> var currentServerContext = escape(document.location); if (window.XMLHttpRequest) {// code for IE7+, Firefox, Chrome, Opera, Safari xmlhttp = new XMLHttpRequest(); } else {// code for IE6, IE5 xmlhttp = new ActiveXObject("Microsoft.XMLHTTP"); } xmlhttp.open("GET","/fv/groups/sitemanager/documents/web_assets/D_008449.xml",false); xmlhttp.send(); xmlDoc=xmlhttp.responseXML; function nonIE7Browser() { var i = 0; var menuID = ""; var divContent = ""; var nodeListObj = xmlDoc.firstChild.childNodes; while (i < nodeListObj.length) { if ((nodeListObj.item(i).nodeType == Node.ELEMENT_NODE) && (nodeListObj.item(i).nodeName == "wcm:element") && nodeListObj.item(i).hasChildNodes()) { var menuID = nodeListObj.item(i).attributes.getNamedItem("name").value; var divContent = nodeListObj.item(i).childNodes[0].nodeValue; if (!currentServerContext.indexOf("ucmstage") >= 0) { divContent = divContent.replace(/'/g, ""); divContent = divContent.replace(/\[\!--\$wcmUrl$resource\,/g, "/fv/"); divContent = divContent.replace(/$--\]/g, ""); document.getElementById(menuID).innerHTML = divContent.replace(/ucmstage.fairview.org\/[Ff]airview/g, "www.fairview.org"); } } i++; } } function IEBrowsers() { var i = 0; var menuID = ""; var divContent = ""; var x = xmlDoc.getElementsByTagName("wcm:element"); while (i < x.length) { if (xmlDoc.getElementsByTagName("wcm:element")[i].hasChildNodes()) { //ignore blank nodes menuID = x[i].attributes.getNamedItem("name").value; divContent = x[i].childNodes[0].nodeValue; if (document.getElementById(menuID) != null) { if (!currentServerContext.indexOf("ucmstage") >= 0) { divContent = divContent.replace(/'/g, ""); divContent = divContent.replace(/\[\!--\$wcmUrl$resource\,/g, "/fv/"); divContent = divContent.replace(/$--\]/g, ""); document.getElementById(menuID).innerHTML = divContent.replace(/ucmstage.fairview.org\/[Ff]airview/g, "www.fairview.org"); } } } i++; } } // Detect Client Browser type var isIE = (navigator.appVersion.indexOf("MSIE") != -1) ? true : false; if (!isIE) { nonIE7Browser(); } else { IEBrowsers(); } </script>  <div class="pageTopSpace"></div>  <div id="contentContainer">  <div class="fullWidth_container"> <div id="pageTopCap" class="png"></div> <div class="fullWidth_content png"> <div id="page-actions"> <div class="page-action" style="display:none"><a href="#"><img src="/web/20120524050041im_/https://sslforms.fairview.org/2/img/buttons/fv_share.jpg" border="0" width="50" height="15" alt="Share This"/></a></div> <div class="page-action"><a href="javascript:window.print()"><img src="/web/20120524050041im_/https://sslforms.fairview.org/2/img/buttons/fv_print.jpg" border="0" width="46" height="15" alt="Print"/></a></div> <div class="page-action" style="display:none"><a href="#"><img src="/web/20120524050041im_/https://sslforms.fairview.org/2/img/buttons/fv_email.jpg" border="0" width="52" height="15" alt="Email This"/></a></div> </div>  <div id="sub-left"> <div id="nav-container"> <div class="smaller" style="text-transform: uppercase; font-weight: lighter;">< <a href="https://web.archive.org/web/20120524050041/http://www.fairview.org/Pharmacy/index.htm">Pharmacy</a></div>  <h2 style="color:#315584;">Prescription Transfers</h2>   <div class="sidebarNav sidebarNavLinks"> <ul> <li><a href="https://web.archive.org/web/20120524050041/https://sslforms.fairview.org/refill.asp" class="Leftnav_table">Prescription Refills</a></li> <li><a href="https://web.archive.org/web/20120524050041/http://www.fairview.org/Pharmacy/Ourpharmacies/index.htm" class="Leftnav_table">Pharmacy Locations</a></li> <li><a href="https://web.archive.org/web/20120524050041/http://www.fairview.org/Pharmacy/Compoundingpharmacy/index.htm" class="Leftnav_table">Compounding Pharmacy</a></li> <li><a href="https://web.archive.org/web/20120524050041/http://www.fairview.org/Pharmacy/Clinicaltrials/index.htm" class="Leftnav_table">Clinical Trials</a></li> <li><a href="https://web.archive.org/web/20120524050041/http://www.fairview.org/Pharmacy/Infusionservices/index.htm" class="Leftnav_table">Infusion Services</a></li> <li><a href="https://web.archive.org/web/20120524050041/http://www.fairview.org/Pharmacy/Mailservice/index.htm" class="Leftnav_table">Mail Service</a></li> <li><a href="https://web.archive.org/web/20120524050041/http://www.fairview.org/Pharmacy/MedicationTherapyManagement/index.htm" class="Leftnav_table">Medication Therapy Management</a></li> <li><a href="https://web.archive.org/web/20120524050041/http://www.fairview.org/Pharmacy/Oncologypharmacy/index.htm" class="Leftnav_table">Oncology Pharmacy</a></li> <li><a href="https://web.archive.org/web/20120524050041/http://www.fairview.org/Pharmacy/Specialtypharmacy/Fertilityprogram/index.htm" class="Leftnav_table">Reproductive Medicine</a></li> <li><a href="https://web.archive.org/web/20120524050041/http://www.fairview.org/Pharmacy/Specialtypharmacy/index.htm" class="Leftnav_table">Specialty Pharmacy</a></li> <li><a href="https://web.archive.org/web/20120524050041/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 Transfers</span> <span class="subtitle"><br> </span><img height="7" alt="" src="https://web.archive.org/web/20120524050041im_/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">   <script language="JavaScript" type="text/JavaScript" src="/web/20120524050041js_/https://sslforms.fairview.org/rxtransfer_validation.js?s=1337817641"></script> <script language="javascript" type="text/javascript" src="/web/20120524050041js_/https://sslforms.fairview.org/refill_pharmacy_logic2.js?s=1337817641"></script> <p align="left" class="fvMainBody">Make refills even more convenient. Use this page to have us transfer your existing prescriptions from another pharmacy to the Fairview Pharmacy of your choice. Just give us a few pieces of information and we'll do the rest.<br/> <br/> <strong>Note:</strong> For your new prescriptions, that you've never had filled before, please visit one of our pharmacies in person.</p> <form action="rxtransfer_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 bgcolor="#F4DD7F"><div class="fvSubHead">Transfer Order</div></th> </tr> <tr align="center"> <th valign="top" style="border: 1px solid #ececec; background: #fffded; padding:3px;"> <p class="subtitle3">How many prescriptions do you wish to transfer?<br> <span style="color: black; font-weight: normal;">(Up to 20 per request)</span><br> <input name="numOfRx" id="numOfRx" onchange="numberOfTransfers(this.value)" onkeyup="numberOfTransfers(this.value)" onblur="numberOfTransfers(this.value)" size="4" maxlength="3" style="font-size: 14px;"> </p> <p class="subtitle3">Which Fairview pharmacy<br/>do you want to transfer your prescriptions to?<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. Village</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> </tr> <tr> <td align="left" valign="top" style="border-right: 1px solid #ececec;"> <table style="width: 48%; float: left; clear: none;"> <tr> <td style="vertical-align: top;"> <p class="subtitle3"><b>First Name:</b></p> </td> <td style="vertical-align: top;"> <input name="firstName" id="firstName" size="20" maxlength="25" style="font-size: 14px;"/> </td> <tr> <td style="vertical-align: top;"> <p class="subtitle3"><b>Last Name:</b></p> </td> <td style="vertical-align: top;"> <input name="lastName" id="Text1" size="20" maxlength="25" style="font-size: 14px;"/><br/> <span>(List patient name if requesting on behalf of minor or spouse)</span> </td> <tr> <td style="vertical-align: top;"> <p class="subtitle3"><b>Email:</b></p> </td> <td style="vertical-align: top;"> <input name="email" id="email" size="20" maxlength="50" style="font-size: 14px;"/> </td> <tr> <td style="vertical-align: top;"> <p class="subtitle3"><b>Confirm Email:</b></p> </td> <td style="vertical-align: top;"> <input name="confirmEmail" type="text" id="confirmEmail" size="20" maxlength="50" style="font-size: 14px;"/> </td> </table> <table style="width: 48%; float: right; clear: none;"> <tr> <td style="vertical-align: top;"> <p class="subtitle3"><b>Phone:</b></p> </td> <td style="vertical-align: top;"> <input name="phoneNumber" id="phoneNumber" size="25" maxlength="15" style="font-size: 14px;"/> </td> <tr> <td style="vertical-align: top;"> <p class="fvMainBody"> <b>Street:</b></p> </td> <td style="vertical-align: top;"> <input name="streetAddress" id="streetAddress" size="25" maxlength="35" style="font-size: 14px;"/> </td> </tr> <tr> <td style="vertical-align: top;"> <p class="fvMainBody"> <b>City:</b></p> </td> <td style="vertical-align: top;"> <input name="City" id="City" size="25" maxlength="15" style="font-size: 14px;"/> </td> </tr> <tr> <td style="vertical-align: top; white-space: nowrap;"> <p class="fvMainBody"> <b>State:</b> </p> </td> <td style="vertical-align: top; white-space: nowrap;"> <p class="fvMainBody"> <input style="margin-right: 1em;" name="State" id="State" size="3" maxlength="15" style="font-size: 14px;"/> <b style="vertical-align: top;">Zip:</b> <input style="margin-left: 1em;" name="Zip" id="Zip" size="8" maxlength="10" style="font-size: 14px;"/> </p> </td> </tr> </table> </td> </tr> <tr align="center" valign="middle" style="background-color: #F4DD7F;"> <th style="border: 1px solid #ececec; padding:3px;"><p class="fvMainBody">Originating Pharmacy</p></th> </tr> <tr> <td align="left" valign="top" style="border-right: 1px solid #ececec;"> <p class="fvMainBody">Please tell us where you fill these prescriptions today.</p> <table> <tr> <td style="vertical-align: top;"> <span class="subtitle3">Pharmacy Name:  </span> </td> <td style="vertical-align: top;"> <input name="origPharmacy" id="origPharmacy" size="25" maxlength="35" style="font-size: 14px;"/> </td> </tr> <tr> <td style="vertical-align: top;"> <span class="subtitle3">City:</span> </td> <td style="vertical-align: top;"> <input name="origPharmacyCity" id="origPharmacyCity" size="25" maxlength="35" style="margin-right: 1em; font-size: 14px;"/> </td> <tr> <td style="vertical-align: top;"> <span class="subtitle3">Phone:</span> </td> <td style="vertical-align: top;"> <input name="origPharmacyPhone" id="origPharmacyPhone" size="25" maxlength="35" style="font-size: 14px;"/> </td> </tr> </table> </td> </tr> <tr align="center" valign="middle" style="background-color: #F4DD7F;"> <th style="border: 1px solid #ececec; padding:3px;"> <p class="fvMainBody">Prescriptions to Transfer</p></th> </tr> <tr> <td align="left" valign="top" style="border-right: 1px solid #ececec;"> <div id="orderNumbers">  </div> <div id="orderMessage">  </div></td> </tr> <tr align="center" valign="middle" style="background-color: #F4DD7F;"> <th style="border: 1px solid #ececec; padding:3px;"><p class="fvMainBody">Pickup or Delivery</p></th> </tr> <tr> <td width="30%" align="left" valign="top" style="border-right: 1px solid #ececec;"> <p class="subtitle3">Please select a delivery method for those prescriptions you want refilled.</p> <table style="width: 100%;"> <tr><td style="vertical-align: top; padding: 0 30px 0 15px; width: 50%;"> <p class="fvMainBody" id="pickUp"><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" style="font-size: 14px;"/></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> </td> <td style="vertical-align: top; padding: 0 15px 0 30px; white-space: nowrap;"> <div id="pharmacyHours" style="display:none;"> The pharmacy hours would be here </div> </td> </tr> </table> </td> </tr> <tr align="center" valign="middle" style="background-color: #F4DD7F;"> <th style="border: 1px solid #ececec; padding:3px;"><p class="fvMainBody">Finalize Your Transfer Request</p></th> </tr> <tr> <td style="padding-left: 15px;"> <p class="fvMainBody"><span class="subtitle3" style="color: black;">Additional comments or instructions</span><br> <textarea name="comments" cols="35" rows="5" id="comments" wrap="hard"></textarea> </p> <p class="fvMainBody">Please note we will make every effort to transfer your prescriptions on a timely basis. However, processing may be delayed depending upon the originating pharmacy.</p>  <div id="formButtons" style="margin-top: 15px; text-align: center;"> <input name="submit" type="submit" id="submit" value="Submit Transfer Request" style="font-size: 14px;"/>      </div> <p class="fvMainBody" style="text-align: center;"><span class="subtitle3">Thank you for choosing Fairview Pharmacy.</span></p> </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. You will need to enable Javascript in order to use this form correctly.</p> </noscript>  </div>  </div>   <div class="clear"></div> </div> </div>    <div id="footerContainer" class="footerSwoosh_above png"> <div class="footerNavBox"> <div id="footerNav"> <div id="Footer_Element_1"></div> <div class="clear"> </div> </div> <div id="footerSubNav"> <div id="Footer_Element_2"></div> <div class="clear"> </div> </div> <div id="Footer_Element_3"></div> <div class="clear"> </div> </div> <div class="footerInfo"> <div id="Footer_Element_4"></div> </div> <div class="clear"> </div> <div class="clear"> </div> </div> <script type="text/javascript"> var currentServerContext = escape(document.location); if (window.XMLHttpRequest) {// code for IE7+, Firefox, Chrome, Opera, Safari xmlhttp = new XMLHttpRequest(); } else {// code for IE6, IE5 xmlhttp=new ActiveXObject("Microsoft.XMLHTTP"); } xmlhttp.open("GET","/fv/groups/sitemanager/documents/web_assets/fairview_footer_content.xml",false); xmlhttp.send(); xmlDoc = xmlhttp.responseXML; function nonIE7Browser() { var i = 0; var menuID = ""; var divContent = ""; var nodeListObj = xmlDoc.firstChild.childNodes; while (i < nodeListObj.length) { if ((nodeListObj.item(i).nodeType == Node.ELEMENT_NODE) && (nodeListObj.item(i).nodeName == "wcm:element") && nodeListObj.item(i).hasChildNodes()) { var menuID = nodeListObj.item(i).attributes.getNamedItem("name").value; var divContent = nodeListObj.item(i).childNodes[0].nodeValue; if (!currentServerContext.indexOf("ucmstage") >= 0) { divContent = divContent.replace(/'/g, ""); divContent = divContent.replace(/\[\!--\$wcmUrl$resource\,/g, "/fv/"); divContent = divContent.replace(/$--\]/g, ""); document.getElementById(menuID).innerHTML = divContent.replace(/ucmstage.fairview.org\/[Ff]airview/g, "www.fairview.org"); } } i++; } } function IEBrowsers() { var i = 0; var menuID = ""; var divContent = ""; var x = xmlDoc.getElementsByTagName("wcm:element"); while(i < x.length) { if (xmlDoc.getElementsByTagName("wcm:element")[i].hasChildNodes()) { //ignore blank nodes menuID = x[i].attributes.getNamedItem("name").value; divContent = x[i].childNodes[0].nodeValue; if (document.getElementById(menuID) != null) { if (!currentServerContext.indexOf("ucmstage") >= 0) { divContent = divContent.replace(/'/g, ""); divContent = divContent.replace(/\[\!--\$wcmUrl$resource\,/g, "/fv/"); divContent = divContent.replace(/$--\]/g, ""); document.getElementById(menuID).innerHTML = divContent.replace(/ucmstage.fairview.org\/[Ff]airview/g, "www.fairview.org"); } } } i++; } } // Detect Client Browser type var isIE = (navigator.appVersion.indexOf("MSIE") != -1) ? true : false; if (!isIE) { nonIE7Browser(); } else { IEBrowsers(); } </script>  </div> </div>  <script type="text/javascript"> var pageTracker = _gat._getTracker("UA-4223671-1"); pageTracker._trackPageview(); </script>  </body> </html>

CINXE.COM

Fairview Pharmacy - Online Prescripton Transfer Form