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<!DOCTYPE html>
<!--
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<html>
<head>
<title>Preview Prescription</title>
<meta charset="UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<link rel='stylesheet' href="https://stackpath.bootstrapcdn.com/bootstrap/4.3.1/css/bootstrap.min.css">
<link rel='stylesheet' href="https://cdnjs.cloudflare.com/ajax/libs/font-awesome/4.0.3/css/font-awesome.css">
<link rel='stylesheet' href="css/custom.css">
</head>
<body>
<div class="container-fluid" id="grad1">
<div class="row justify-content-center mt-0">
<div class="col-11 col-sm-12 col-md-6 col-lg-12 text-center p-0 mb-2">
<div class="form-card card px-0 pb-0 mb-3">
<div class="display-flex header-container">
<div class="col-md-4"></div>
<div class="header-pres col-md-4"><h4>PRESCRIPTION</h3></div>
<div class="col-md-4 header_date text-right"><b>May 19, 2021</b></div>
</div>
<div class="cont display-flex">
<div class='patient-info col-12 col-md-6' >
<strong>Patient Information</strong>
<div class="display-flex">
<div class='left-title'> Name
<div>:</div>
</div>
<div class="d-flex"> Corona, Sara</div>
</div>
<div class="display-flex">
<div class='left-title'> Gender
<div>:</div>
</div>
<div> Female</div>
</div>
<div class="display-flex">
<div class='left-title'> Date of Birth
<div>:</div>
</div>
<div> 02-08-1984</div>
</div>
<div class="display-flex">
<div class='left-title'> Street Address
<div>:</div>
</div>
<div class="d-flex"> 404 WEBSTER DR. ALAMOGORDO, NM 88310</div>
</div>
<div class="display-flex">
<div class='left-title'> Phone
<div>:</div>
</div>
<div> (423)-412-3213</div>
</div>
</div>
<div class='prescriber-info col-12 col-md-6' >
<strong>Prescriber Information</strong>
<div class="display-flex">
<div class='left-title'> Name
<div>:</div>
</div>
<div class="d-flex"> Enriquez, Claudia</div>
</div>
<div class="display-flex">
<div class='left-title'> NPI
<div>:</div>
</div>
<div> 3212453454</div>
</div>
<div class="display-flex">
<div class='left-title'> Address
<div>:</div>
</div>
<div class="d-flex"> 2474 Indian wells rd, Alamogordo, Nm 88310-3845</div>
</div>
<div class="display-flex">
<div class='left-title'> Phone
<div>:</div>
</div>
<div> (575)-234-3243</div>
</div>
</div>
</div>
<div class="drug-table">
<div class="drugName">
<div><b>COMMERCIAL PRESCRIPTION</b></div>
<div style="color:#003865;font-weight:bold">Xolair 150 mg vial <i class="fa fa-pencil"></i></div>
</div>
<div style="text-align: left;padding: 1%;">
<div class="display-flex">
<div class='left-title'> NDC
<div>:</div>
</div>
<div> 4234123213123</div>
</div>
<div class="display-flex">
<div class='left-title'> Sig
<div>:</div>
</div>
<div class="d-flex"> INHALE 36 UNITS BY MOUTH THREE TIMES DAILY WITH MAXIMUM DAILY DOSAGE 108 UNITS</div>
</div>
<div class="display-flex">
<div class='left-title'> Quantity
<div>:</div>
</div>
<div> 270</div>
</div>
<div class="display-flex">
<div class='left-title'> Days Supply
<div>:</div>
</div>
<div> 2 Weeks</div>
</div>
<div class="display-flex">
<div class='left-title'> ICD Codes
<div>:</div>
</div>
<div> 011, 013</div>
</div>
<div class="display-flex">
<div class='left-title'> Notes to pharmacists
<div>:</div>
</div>
<div class="d-flex"> Please pack the medicine carefully</div>
</div>
</div>
</div>
<div class='prescriber-info col-md-12 col-12'>
<strong>Pharmacy Information</strong>
<div class="display-flex">
<div class='left-title'> Name
<div>:</div>
</div>
<div class="d-flex"> STRLING SPECIALITY PHARMACY</div>
</div>
<div class="display-flex">
<div class='left-title'> Address
<div>:</div>
</div>
<div class="d-flex"> 1312 Northland Dr. Mendota Height, MN 55120-1140</div>
</div>
<div class="display-flex">
<div class='left-title'> Phone
<div>:</div>
</div>
<div> (575)-234-3243</div>
</div>
<div class="display-flex">
<div class='left-title'> Fax
<div>:</div>
</div>
<div> (575)-234-3243</div>
</div>
<div class="display-flex">
<div class='left-title'> NPI
<div>:</div>
</div>
<div> 1447680210</div>
</div>
<div class="display-flex">
<div class='left-title'> NCPDP
<div>:</div>
</div>
<div> 5910206</div>
</div>
</div>
<div class="drug-table">
<div class="drugName">
<div><b>BRIDGE PRESCRIPTION</b></div>
<div style="color:#003865;font-weight:bold">Xolair 150 mg vial <i class="fa fa-pencil"></i></div>
</div>
<div style="text-align: left;padding: 1%;">
<div class="display-flex">
<div class='left-title'> NDC
<div>:</div>
</div>
<div> 4234123213123</div>
</div>
<div class="display-flex">
<div class='left-title'> Sig
<div>:</div>
</div>
<div class="d-flex"> INHALE 36 UNITS BY MOUTH THREE TIMES DAILY WITH MAXIMUM DAILY DOSAGE 108 UNITS</div>
</div>
<div class="display-flex">
<div class='left-title'> Quantity
<div>:</div>
</div>
<div> 270</div>
</div>
<div class="display-flex">
<div class='left-title'> Days Supply
<div>:</div>
</div>
<div> 2 Weeks</div>
</div>
<div class="display-flex">
<div class='left-title'> ICD Codes
<div>:</div>
</div>
<div> 011, 013</div>
</div>
<div class="display-flex">
<div class='left-title'> Notes to pharmacists
<div>:</div>
</div>
<div class="d-flex"> Please pack the medicine carefully</div>
</div>
</div>
</div>
<div class='prescriber-info col-md-12'>
<strong>Pharmacy Information</strong>
<div class="display-flex">
<div class='left-title'> Name
<div>:</div>
</div>
<div class="d-flex"> Sonexus Health Pharmacy Services</div>
</div>
<div class="display-flex">
<div class='left-title'> Address
<div>:</div>
</div>
<div class="d-flex"> 2730 S. Edmonds Lane #400, Lewiswille, TX 75067</div>
</div>
<div class="display-flex">
<div class='left-title'> Phone
<div>:</div>
</div>
<div> (575)-234-3243</div>
</div>
<div class="display-flex">
<div class='left-title'> Fax
<div>:</div>
</div>
<div> (575)-234-3243</div>
</div>
<div class="display-flex">
<div class='left-title'> NPI
<div>:</div>
</div>
<div> 1447680210</div>
</div>
<div class="display-flex">
<div class='left-title'> NCPDP
<div>:</div>
</div>
<div> 5910206</div>
</div>
</div>
<div>
<center><button style="width: 300px;" class="pharmacy-button btn btn-block btn-danger btn-lg">Send Prescription to Pharmacy</button></center>
</div>
</div>
</div>
</div>
</div>
<style>
.header-container{
justify-content: space-evenly;
align-items: center;
margin-bottom: 30px;
padding: 10px;
background-color: #003865;
color: white;
}
.fa-pencil{
color: #FF7F32;
margin-left: 10px;
font-size: 18px;
cursor: pointer;
}
.fa-pencil:hover{
transform: scale(1.2);
}
.header-pres h4{
margin-bottom:0px;
}
.pharmacy-button{
background-color:#EF426F;
color: white;
border: none;
border-radius: 5px;
padding: 10px 20px 10px 20px;
margin-top: 20px;
}
.drugName{
display: flex;
justify-content: space-between;
background-color: #0038651f;
padding: 1%;
}
.drug-table{
margin: 1%;
border: 2px solid #0038651f;
}
.cont{
justify-content: space-around;
flex-wrap: wrap;
}
.left-title{
width: 150px;
float: left;
display: flex;
justify-content: space-between;
margin-right: 2px;
}
.prescriber-info, .patient-info{
text-align: left;
}
.form-card.card{
box-shadow: none;
padding : 20px 0 !important;
padding-top:0px !important;
}
@media only screen and (max-width: 800px) {
.display-flex {
display: block !important;
}
.header_date{
text-align: center !important;
}
.drugName{
flex-wrap: wrap;
align-items: flex-start;
flex-direction: column;
}
.drug-table{
margin-top: 10px;
margin-bottom: 10px;
}
}
</style>
<script src="https://cdnjs.cloudflare.com/ajax/libs/jquery/3.2.1/jquery.min.js"></script>
<script src="https://stackpath.bootstrapcdn.com/bootstrap/4.3.1/js/bootstrap.bundle.min.js"></script>
<script src="js/custom.js"></script>
</body>
</html>