</p> <div class="MainPublicBlankMasterContent"> <style type="text/css"> .hidden { visibility: hidden !important; } </style> <p> <script type="text/javascript"> function runBeforeSubmitFunctions() { }</p> <p> function runReadyFunctions() { try { if (window.refillWizardRefillInformationControlReady) { refillWizardRefillInformationControlReady(); }</p> <p> if (window.refillWizardAutoFillOptionsControlReady) { refillWizardAutoFillOptionsControlReady(); }</p> <p> if (window.refillWizardReviewControlReady) { refillWizardReviewControlReady(); } } catch (e) { } } </script></p> <div id="MainContentArea_MainContentArea_MainContentArea_pnlLoading" class="RadAjax RadAjax_Vista" style="display:none;"> <div class="raDiv"></div> <div class="raColor raTransp"></div> </div> <div id="MainContentArea_MainContentArea_MainContentArea_ctl00$ctl00$ctl00$MainContentArea$MainContentArea$MainContentArea$pnlWizardPanel" style="display: block;"> <div id="MainContentArea_MainContentArea_MainContentArea_pnlWizard"> <div id="refillWizardContainer" class=""> <div id="refillNavigationBreadcrumb"> <p><span class="active">1. Refill Information</span><br /> <span class="breadcrumbSeparator">></span><br /> <span>2. Accept Terms Of Use</span><br /> <span class="breadcrumbSeparator">></span><br /> <span>3. View Refills</span><br /> <span class="breadcrumbSeparator">></span><br /> <span>4. Pickup Options</span><br /> <span class="breadcrumbSeparator">></span><br /> <span>5. Pickup Time</span><br /> <span class="breadcrumbSeparator">></span><br /> <span>6. Review</span><br /> <span class="breadcrumbSeparator">></span><br /> <span>7. Receipt</span></p></div> <div class="errorSummary"> <div id="MainContentArea_MainContentArea_MainContentArea_es_ctl00" class="newTechValidationSummary" style="font-weight:normal;text-decoration:none;display:none;"></div> </p></div> <div id="refillWizardStepSwitcherContainer"> <div id="MainContentArea_MainContentArea_MainContentArea_mvSteps"> <div id="MainContentArea_MainContentArea_MainContentArea_viewRefillInformation"> <div class="refillImage refillInformation"></div> <p><script type="text/javascript"> var txtRxNumberClientID = 'MainContentArea_MainContentArea_MainContentArea_refillInformation_txtRxNumber_text'; var txtLastNameClientID = 'MainContentArea_MainContentArea_MainContentArea_refillInformation_txtLastName_text'; var txtPhoneNumberClientID = 'MainContentArea_MainContentArea_MainContentArea_refillInformation_txtPhoneNumber_text'; var txtDateOfBirthClientID = 'MainContentArea_MainContentArea_MainContentArea_refillInformation_txtDateOfBirth_text'; var txtEmailAddressClientID = 'MainContentArea_MainContentArea_MainContentArea_refillInformation_txtEmailAddress_text';</p> <p> function turnOffAutoCompleteForRefillInformation() { $('#' + txtRxNumberClientID).attr("autocomplete", "off"); $('#' + txtLastNameClientID).attr("autocomplete", "off"); $('#' + txtPhoneNumberClientID).attr("autocomplete", "off"); $('#' + txtDateOfBirthClientID).attr("autocomplete", "off"); $('#' + txtEmailAddressClientID).attr("autocomplete", "off"); }</p> <p> function setFocus(){ var combo = $find('MainContentArea_MainContentArea_MainContentArea_refillInformation_drpLocation'); var comboLoggedOn = $find('MainContentArea_MainContentArea_MainContentArea_refillInformation_drpLocationLoggedOn'); var rx = $find('MainContentArea_MainContentArea_MainContentArea_refillInformation_txtRxNumber');</p> <p> if (combo && combo.get_inputDomElement && combo.get_inputDomElement() && combo.get_inputDomElement().focus && $(combo.get_inputDomElement()).val() == 'Please select a location') { combo.get_inputDomElement().focus(); } else if (comboLoggedOn && comboLoggedOn.get_inputDomElement && comboLoggedOn.get_inputDomElement() && comboLoggedOn.get_inputDomElement().focus && $(comboLoggedOn.get_inputDomElement()).val() == 'Please select a location') { comboLoggedOn.get_inputDomElement().focus(); } else if (rx && rx.focus) { rx.focus(); } }</p> <p> function refillWizardRefillInformationControlReady() { window.setTimeout(turnOffAutoCompleteForRefillInformation, 100); window.setTimeout(setFocus, 100); }</p> <p> $(document).ready(refillWizardRefillInformationControlReady); </script></p> <div id="refillInformationLogonGroup"> <div id="refillInformationContainer"> <div id="labelImageContainer"> <img decoding="async" id="MainContentArea_MainContentArea_MainContentArea_refillInformation_imgLabel" title="rx label" src="../../Download/Image/3291" alt="rx label"> </div> <div class="wizardHeader"><span></span>Refill Information</div> <div class="refillInformation editFields"> <div class="editItem"> <div class="editLabel"> <label for="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtRxNumber" id="MainContentArea_MainContentArea_MainContentArea_refillInformation_lblRxNumber">Rx Number</label><br /> <span class="requiredFieldIndicator">*</span> </div> <div class="editValue"> <span id="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtRxNumber_wrapper" class="RadInput RadInput_Vista" style="white-space:normal;"><input type="text" id="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtRxNumber_text" name="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtRxNumber_text" class="riTextBox riEnabled radInput" style="width:125px;" maxlength="2147483647" autocomplete="off"><input style="visibility:hidden;margin:-18px 0 0 -1px;width:1px;height:1px;overflow:hidden;border:0;padding:0;" id="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtRxNumber" class="rdfd_" value="" type="text"><input style="visibility:hidden;margin:-18px 0 0 -1px;width:1px;height:1px;overflow:hidden;border:0;padding:0;" id="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtRxNumber_Value" class="rdfd_" name="ctl00$ctl00$ctl00$MainContentArea$MainContentArea$MainContentArea$refillInformation$txtRxNumber" value="" type="text"><input id="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtRxNumber_ClientState" name="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtRxNumber_ClientState" type="hidden" autocomplete="off"></span><span id="MainContentArea_MainContentArea_MainContentArea_refillInformation_rfvRxNumber" style="visibility:hidden;">*</span> </div> </p></div> <div class="editItem"> <div class="editLabel"> <label for="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtLastName" id="MainContentArea_MainContentArea_MainContentArea_refillInformation_lblLastName">Patient Last Name</label><br /> <span class="requiredFieldIndicator">*</span> </div> <div class="editValue"> <span id="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtLastName_wrapper" class="RadInput RadInput_Vista" style="white-space:normal;"><input autocomplete="off" type="text" maxlength="50" size="20" id="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtLastName_text" name="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtLastName_text" class="riTextBox riEnabled textBox" style="width:125px;"><input id="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtLastName" name="ctl00$ctl00$ctl00$MainContentArea$MainContentArea$MainContentArea$refillInformation$txtLastName" class="rdfd_" style="visibility:hidden;margin:-18px 0 0 -1px;width:1px;height:1px;overflow:hidden;border:0;padding:0;" type="text" value=""><input id="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtLastName_ClientState" name="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtLastName_ClientState" type="hidden" autocomplete="off"></span><span id="MainContentArea_MainContentArea_MainContentArea_refillInformation_rfvLastName" style="visibility:hidden;">*</span> </div> </p></div> <div class="editItem"> <div class="editLabel"> <label for="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtPhoneNumber" id="MainContentArea_MainContentArea_MainContentArea_refillInformation_lblPhoneNumber">Patient Phone Number</label><br /> <span class="requiredFieldIndicator">*</span><br /> <span id="MainContentArea_MainContentArea_MainContentArea_refillInformation_revPhone" style="display:none;">*</span> </div> <div class="editValue"> <span id="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtPhoneNumber_wrapper" class="RadInput RadInput_Vista" style="white-space:normal;"><input type="text" size="20" value="(___) ___-____" id="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtPhoneNumber_text" name="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtPhoneNumber_text" class="riTextBox riEnabled radInput" style="width:125px;" autocomplete="off"><input style="visibility:hidden;margin:-18px 0 0 -1px;width:1px;height:1px;overflow:hidden;border:0;padding:0;" id="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtPhoneNumber" value="() -" class="rdfd_" type="text"><input style="visibility:hidden;margin:-18px 0 0 -1px;width:1px;height:1px;overflow:hidden;border:0;padding:0;" id="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtPhoneNumber_Value" name="ctl00$ctl00$ctl00$MainContentArea$MainContentArea$MainContentArea$refillInformation$txtPhoneNumber" class="rdfd_" value="() -" type="text"><input id="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtPhoneNumber_ClientState" name="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtPhoneNumber_ClientState" type="hidden" autocomplete="off"></span><span id="MainContentArea_MainContentArea_MainContentArea_refillInformation_rfvPhoneNumber" style="visibility:hidden;">*</span> </div> </p></div> <div class="editItem"> <div class="editLabel"> <label for="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtDateOfBirth" id="MainContentArea_MainContentArea_MainContentArea_refillInformation_lblDateOfBirth">Patient Date of Birth</label><br /> <span class="requiredFieldIndicator">*</span> </div> <div class="editValue"> <span id="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtDateOfBirth_wrapper" class="RadInput RadInput_Default" style="white-space:normal;"><input type="text" value="mm/dd/yyyy" id="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtDateOfBirth_text" name="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtDateOfBirth_text" class="riTextBox riEmpty radInput" style="width:125px;" autocomplete="off"><input style="visibility:hidden;margin:-18px 0 0 -1px;width:1px;height:1px;overflow:hidden;border:0;padding:0;" id="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtDateOfBirth" name="ctl00$ctl00$ctl00$MainContentArea$MainContentArea$MainContentArea$refillInformation$txtDateOfBirth" class="rdfd_" type="text"><input id="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtDateOfBirth_ClientState" name="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtDateOfBirth_ClientState" type="hidden" value="{"enabled":true,"emptyMessage":"mm/dd/yyyy","minDateStr":"1/1/1850 0:0:0","maxDateStr":"12/31/9999 0:0:0"}" autocomplete="off"></span><span id="MainContentArea_MainContentArea_MainContentArea_refillInformation_rfvDateOfBirth" style="visibility:hidden;">*</span> </div> </p></div> <div class="editItem"> <div class="editLabel"> <label for="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtEmailAddress" id="MainContentArea_MainContentArea_MainContentArea_refillInformation_lblEmailAddress">Email Address</label> </div> <div class="editValue"> <span id="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtEmailAddress_wrapper" class="RadInput RadInput_Vista" style="white-space:normal;"><input autocomplete="off" type="text" maxlength="255" size="20" id="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtEmailAddress_text" name="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtEmailAddress_text" class="riTextBox riEnabled textBox" style="width:125px;"><input id="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtEmailAddress" name="ctl00$ctl00$ctl00$MainContentArea$MainContentArea$MainContentArea$refillInformation$txtEmailAddress" class="rdfd_" style="visibility:hidden;margin:-18px 0 0 -1px;width:1px;height:1px;overflow:hidden;border:0;padding:0;" type="text" value=""><input id="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtEmailAddress_ClientState" name="MainContentArea_MainContentArea_MainContentArea_refillInformation_txtEmailAddress_ClientState" type="hidden" autocomplete="off"></span><span id="MainContentArea_MainContentArea_MainContentArea_refillInformation_revEmailAddress" style="visibility:hidden;">*</span> </div> </p></div> </p></div> <div class="requiredFieldIndicatorLegend"> * Required Fields</div> </p></div> <div id="registerInformationContainer" class="editFields"> <div class="editHeader">Create an Account</div> <div id="registerDescription"> <div class="listHeader">Creating an online account allows you to:</div> <ul> <li>Not have to re-enter information for every refill.</li> <li>Track refill requests online.</li> <li>Receive prescription notifications via email.</li> </ul> <p> <a 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