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<html style="height: auto; min-height: 100%;"><head>
<meta charset="utf-8">
<meta http-equiv="X-UA-Compatible" content="IE=edge">
<title>New Prescription</title>
<link rel="shortcut icon" href="https://qaspnrx.evincemed.net/assets/common/favicon.ico" type="image/x-icon">
<link rel="icon" href="https://qaspnrx.evincemed.net/assets/common/favicon.ico" type="image/x-icon">
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<meta content="width=device-width, initial-scale=1, maximum-scale=1, user-scalable=no" name="viewport">
<!-- Bootstrap 3.3.7 -->
<link rel="stylesheet" href="https://qaspnrx.evincemed.net/assets/bower_components/bootstrap/dist/css/bootstrap.min.css">
<!-- Font Awesome -->
<link rel="stylesheet" href="https://qaspnrx.evincemed.net/assets/bower_components/font-awesome/css/font-awesome.min.css">
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<script src="https://qaspnrx.evincemed.net/assets/bower_components/jquery-ui/jquery-ui.min.js"></script> -->
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<!-- Resolve conflict in jQuery UI tooltip with Bootstrap tooltip -->
<script>
$.widget.bridge('uibutton', $.ui.button);
</script>
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<!-- datepicker -->
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<!-- DataTables -->
<script src="https://qaspnrx.evincemed.net/assets/bower_components/datatables.net/js/jquery.dataTables.min.js"></script>
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<script type="text/javascript">
//<![CDATA[
base_url = 'https://qaspnrx.evincemed.net/';
//]]>
</script>
<!-- jquery-confirm files -->
<link rel="stylesheet" type="text/css" href="https://qaspnrx.evincemed.net/assets/plugins/jquery-confirm/css/jquery-confirm.css">
<script type="text/javascript" src="https://qaspnrx.evincemed.net/assets/plugins/jquery-confirm/js/jquery-confirm.js"></script>
<!--END jquery-confirm files-->
<style>
@import url('https://fonts.googleapis.com/css2?family=Poppins:ital,wght@0,200;0,300;0,500;0,700;1,200;1,300;1,500;1,700&display=swap');
@import url('https://fonts.googleapis.com/css2?family=Open+Sans:ital,wght@0,300;0,400;0,700;0,800;1,300;1,400;1,700;1,800&display=swap');
body{
font-family: 'Open Sans',sans-serif !important;
}
h1,h2,h3,h4,h5,h6{
font-family: 'Poppins', sans-serif !important;
}
.main-header .navbar{
margin-left: 0px !important;
}
.content-wrapper, .main-footer{
margin-left: 0px !important;
}
.wrapper{
background-color: #ffffff !important;
}
.layout-boxed .wrapper{
box-shadow: none !important;
}
.content-wrapper{
padding: 20px 100px 45px 100px !important;
}
.u12_div {
height: 60px;
font-size: 15px;
color: #fff;
display: flex;
align-items: center;
padding: 0px 2% 0px 2%;
justify-content: space-between;
border-width: 0px;
left: 0px;
top: 0px;
background: inherit;
background-color: #003865;
border: none;
border-radius: 0px;
-moz-box-shadow: none;
-webkit-box-shadow: none;
box-shadow: none;
}
.field_error{
border:1px solid red !important;
}
.btn-danger{
background-color: #EF426F !important;
border-color: #EF426F !important;
}
/*Prescription css*/
.diagnosis_code_title{
position: absolute;
background: #fff;
top: -10px;
left: 20px;
padding: 0 10px;
}
.diagnosis_code_section{
margin-top: 20px;
padding-right: 30px;
}
@media (max-width: 991px) {
}
@media (max-width: 767px) {
.content-wrapper{
padding: 20px 5px !important;
}
}
@media only screen and (max-width: 768px) {
/* For mobile phones: */
.section-title {
padding: 1%;
}
.u12_div {
height: 130px;
flex-direction: column;
align-items: flex-start;
justify-content: center;
}
.u12_div .pull-right {
text-align: inherit !important;
}
.box-title{
text-align: center;
}
#diagnosisCode1, #diagnosisCode2{
width: 100% !important;
margin-right: 0 !important;
}
.diagnosis_code_section{
width: 100%;
float: left;
margin-bottom: 20px;
}
}
</style>
<!-- HTML5 Shim and Respond.js IE8 support of HTML5 elements and media queries -->
<!-- WARNING: Respond.js doesn't work if you view the page via file:// -->
<!--[if lt IE 9]>
<script src="https://oss.maxcdn.com/html5shiv/3.7.3/html5shiv.min.js"></script>
<script src="https://oss.maxcdn.com/respond/1.4.2/respond.min.js"></script>
<![endif]-->
<!-- Google Font -->
<link rel="stylesheet" href="https://fonts.googleapis.com/css?family=DM+Sans:300,400,600,700,300italic,400italic,600italic">
</head>
<body class="skin-blue layout-boxed" style="height: auto; min-height: 100%;">
<!-- Site wrapper -->
<div class="wrapper" style="overflow: hidden; height: auto; min-height: 100%;" id="ajaxPageHolder"><!-- Left side column. contains the logo and sidebar -->
<div class="u12_div">
<div style="float: left; padding:6px;">
36 years old, M, Talofofo, GU <br>
Maki, Deke </div>
<div class="pull-right" style="padding:6px;">
<b>New Prescription</b> <br>
Xolair 150 mg vial </div>
</div>
<!--<script type="text/javascript" src="https://qaspnrx.evincemed.net/assets/check_browser_tab_close.js"></script>-->
<style>
.section-title{
background-color: #0038651f;
margin-left: 2%;
width: 95.6%;
margin-bottom: 10px;
}
.section-title h4{
font-size: 16px;
font-weight: bold;
color: #003865;
}
.small, small {
font-size: 70%;
font-style: italic;
}
</style>
<script>
$(document).ready(function () {
// Send data to Server
$('#preview_btn').click(function (e) {
e.preventDefault();
var errMsg = [];
var ordering_prescriber = $("#ordering_prescriber").val();
var bridge_drugSigText = $("#bridge_drugSigText").val();
var bridge_drugQuantity = $("#bridge_drugQuantity").val();
var bridge_drugDaysSupply = $('#bridge_drugDaysSupply').val();
var commercial_drugSigText = $("#commercial_drugSigText").val();
var commercial_drugQuantity = $("#commercial_drugQuantity").val();
var commercial_drugDaysSupply = $('#commercial_drugDaysSupply').val();
if (ordering_prescriber == '') {
$('#ordering_prescriber').addClass('field_error');
errMsg.push(' Please enter ordering prescriber ');
} else {
$('#ordering_prescriber').removeClass('field_error');
}
if (commercial_drugSigText == '') {
$('#commercial_drugSigText').addClass('field_error');
errMsg.push(' Please enter commercial pharmacy Signote ');
} else {
$('#commercial_drugSigText').removeClass('field_error');
}
if (commercial_drugQuantity == '') {
$('#commercial_drugQuantity').addClass('field_error');
errMsg.push(' Please enter commercial pharmacy drug quantity ');
} else {
$('#commercial_drugQuantity').removeClass('field_error');
}
if (commercial_drugDaysSupply == '') {
$('#commercial_drugDaysSupply').addClass('field_error');
errMsg.push(' Please enter commercial pharmacy drug days supply');
} else {
$('#commercial_drugDaysSupply').removeClass('field_error');
}
if (bridge_drugSigText == '') {
$('#bridge_drugSigText').addClass('field_error');
errMsg.push(' Please enter bridge pharmacy Signote ');
} else {
$('#bridge_drugSigText').removeClass('field_error');
}
if (bridge_drugQuantity == '') {
$('#bridge_drugQuantity').addClass('field_error');
errMsg.push(' Please enter bridge pharmacy drug quantity ');
} else {
$('#bridge_drugQuantity').removeClass('field_error');
}
if (bridge_drugDaysSupply == '') {
$('#bridge_drugDaysSupply').addClass('field_error');
errMsg.push(' Please enter bridge pharmacy drug days supply');
} else {
$('#bridge_drugDaysSupply').removeClass('field_error');
}
if (errMsg.toString() != "") {
$.confirm({
icon: 'fa fa-warning',
theme: 'modern',
closeIcon: true,
animation: 'scale',
type: 'red',
title: 'Alert!',
content: errMsg.toString(),
buttons: {
close: function () {
}
}
});
return false;
} else {
//alert('Form will be submit!');
$('#preview_btn').attr('disabled', 'true');
// setup some local variables
var $form = $('#prescriptionForm');
var serializedData = $form.serializeArray();
$.post("https://qaspnrx.evincemed.net/v1/erx/post_process_erx_form", serializedData, function (data) {
// Display the returned data in browser
console.log(data);
$.get("https://qaspnrx.evincemed.net/v1/erx/preview_erx_form/1EB007FCED2053AF9D138C563610540B", function (res, status) {
$("#ajaxPageHolder").html(res);
});
/*
$.confirm({
icon: 'fa fa-success',
theme: 'modern',
closeIcon: false,
animation: 'scale',
type: 'green',
title: 'Alert!',
content: "Form data are saved!",
buttons: {
close: function () {
$.get("https://qaspnrx.evincemed.net/v1/erx/preview_erx_form/1EB007FCED2053AF9D138C563610540B", function(res, status){
$("#ajaxPageHolder").html(res);
});
//window.location.replace("https://qaspnrx.evincemed.net/v1/erx/preview_erx_form/");
}
}
});
*/
});
}
});
});
</script>
<section class="content">
<div class="box box-default">
<div class="box-header no-border">
<div class="box-tools pull-right">
</div>
</div>
<!-- /.box-header -->
<form method="post" id="prescriptionForm">
<input type="hidden" name="ref_id" value="1EB007FCED2053AF9D138C563610540B">
<input type="hidden" name="auth_username" value="amgen">
<input type="hidden" name="sso_userID" value="devuser">
<input type="hidden" name="EMID" value="22150">
<input type="hidden" name="UPID" value="1518961887001">
<input type="hidden" name="PatientFirstName" value="Deke">
<input type="hidden" name="PatientLastName" value="Maki">
<input type="hidden" name="PatientGender" value="M">
<input type="hidden" name="PatientDob" value="19850811">
<input type="hidden" name="PatientAddressLine1" value="11 Talofofo Road">
<input type="hidden" name="PatientAddressLine2" value="4A">
<input type="hidden" name="PatientCity" value="Talofofo">
<input type="hidden" name="PatientState" value="GU">
<input type="hidden" name="PatientZip" value="969150000">
<input type="hidden" name="PatientPhone" value="9685968500">
<input type="hidden" name="PrescriberFirstName" value="FRANCIS">
<input type="hidden" name="PrescriberLastName" value="PICCIONE">
<input type="hidden" name="PrescriberNpi" value="1518961887">
<input type="hidden" name="PrescriberAddressLine1" value="718 SMYTH RD">
<input type="hidden" name="PrescriberAddressLine2" value="">
<input type="hidden" name="PrescriberCity" value="MANCHESTER">
<input type="hidden" name="PrescriberState" value="NH">
<input type="hidden" name="PrescriberZip" value="031047007">
<input type="hidden" name="PrescriberPhone" value="6036244366">
<input type="hidden" name="PrescriberFax" value="6030304304">
<input type="hidden" name="PharmacyName" value="Rapid-Rx Online Pharmacy">
<input type="hidden" name="PharmacyNCPDP" value="8455475">
<input type="hidden" name="PharmacyPhoneNo" value="8884241147">
<input type="hidden" name="BridgePharmacyName" value="">
<input type="hidden" name="BridgePharmacyNPI" value="">
<input type="hidden" name="BridgePharmacyNCPDP" value="">
<input type="hidden" name="BridgePharmacyPhoneNo" value="">
<div class="box-body">
<div class="row">
<div class="col-md-6 form-group">
<label for="ordering_prescriber">Ordering /Prescribing Physician<sup style="color: red;">*</sup></label>
<input type="text" class="form-control requiredval" required="true" disabled value="PICCIONE, FRANCIS" name="ordering_prescriber" id="ordering_prescriber" placeholder="">
</div>
<div class="col-md-6 form-group">
<label for="prescriberNpi">Prescriber Information</label><br>
<strong>Address:</strong> 718 SMYTH RD, MANCHESTER, NH, 03104-7007<br>
<strong>Phone:</strong> (603)-624-4366  <strong>Fax:</strong> (603)-030-4304 </div>
</div>
<!-- /.row -->
<br>
<div class="row">
<div class="col-md-6" style="padding-left: 0px;">
<input type="hidden" name="commercial[DrugDescription]" value="Xolair 150 mg vial">
<input type="hidden" name="commercial[DrugNDC]" value="68084072211">
<div class="col-md-12 section-title">
<h4 class="box-title">COMMERCIAL PHARMACY PRESCRIPTION</h4>
</div>
<div class="col-md-12 form-group">
<label for="commercial_drugSigText">Sig.<sup style="color: red;">*</sup> <small>max 140 characters</small></label>
<input type="text" class="form-control requiredval" value="Inject 225 mg subcutaneously once every 2 weeks" name="commercial[DrugSigText]" required="true" id="commercial_drugSigText" placeholder="">
</div>
<!-- <div class="col-md-12 form-group">
<label for="commercial_QuantityUnitOfMeasure">Package Unit <small>optional</small></label>
<input type="text" class="form-control" value="C64933" name="commercial[QuantityUnitOfMeasure]" id="commercial_QuantityUnitOfMeasure" placeholder="">
</div> -->
<div class="col-md-12 form-group">
<label for="commercial_drugQuantity">Quantity<sup style="color: red;">*</sup> </label>
<input type="text" class="form-control requiredval numval" value="6" name="commercial[DrugQuantity]" required="true" id="commercial_drugQuantity" placeholder="">
</div>
<div class="col-md-12 form-group">
<label for="commercial_drugDaysSupply">Days Supply<sup style="color: red;">*</sup></label>
<input type="text" class="form-control requiredval numval" value="60" name="commercial[DrugDaysSupply]" required="true" id="commercial_drugDaysSupply" placeholder="">
</div>
<!-- <div class="col-md-12 form-group">
<label for="commercial_drugNumberOfRefills">Refills</label>
<input type="text" class="form-control numval" value="1" name="commercial[DrugNumberOfRefills]" id="commercial_drugNumberOfRefills" placeholder="">
</div>-->
<div class="col-md-12 form-group">
<label for="commercial_notesToPharmacy">Notes to Pharmacy</label>
<input type="text" class="form-control" value="" name="commercial[NotesToPharmacy]" id="commercial_notesToPharmacy" placeholder="">
</div>
<div class="col-md-12 form-group">
<label>Select Pharmacy:</label>
<select class="form-control" name="PharmacyNPI">
<option value="2245665890">Rapid-Rx Online Pharmacy</option>
<option value="2147483647">Walgreens Drug Store 59378</option><option value="2147483647">Walgreens Drug Store 59395</option><option value="2147483647">Walgreen WE-PRE Drug Store 59908</option><option value="2147483647">Walgreen Drug Store 59908</option><option value="2147483647">VPEX MOP</option><option value="2147483647">MSHA Test</option><option value="2147483647">CNR PHARMACY SOUTH</option><option value="2147483647">KMT PHARM ITHACA</option><option value="2147483647">AMY PPI FACILITY</option><option value="2147483647">GARIMA PPI FACILITY</option><option value="2147483647">COREY PPI FACILITY</option><option value="2147483647">NDC PPI Test Facility</option><option value="2147483647">jab pharm one</option><option value="2147483647">Cecylia Pharm One</option><option value="2147483647">Hawaii TAMC Pharmacy 10.6MU</option><option value="2147483647">HEB 895</option><option value="2147483647">WIS Jacksonville (028)</option><option value="2147483647">ECH PHARM ONE - DISPLAY NAME</option><option value="2147483647">ECH PHARM ONE</option><option value="2147483647">SKM Pharm One</option><option value="2147483647">IFW PACIFIC PHARMACY</option><option value="2147483647">IFW PHARM ONE</option><option value="2147483647">BAMA Pharm One</option><option value="2147483647">Retail Advantage</option><option value="2147483647">TJK Pharm One</option><option value="2147483647">ALS Outpatient Pharm</option><option value="2147483647">CNR PHARMACY SOUTH</option><option value="2147483647">Costco Test # 8178</option><option value="2147483647">CNR Pharmacy South</option><option value="2147483647">EMDEON TEST STORE</option><option value="2147483647">MadeupPharmacyWithAReallyLongNameFo</option><option value="2147483647">TEST PHARMACY &%\S\ WITH A LONG NAME!</option><option value="2147483647">Test Diamond Pharmacy</option><option value="2147483647">Very Long Injured Workers Pharmacy!</option><option value="2147483647">Best Computing Test</option><option value="2147483647">SureScripts Test Pharm - Fax</option><option value="2147483647">Test000 Pharmacy Store 10.6</option><option value="2147483647">CA Pharmacy Store 10.6 EDIFACT</option><option value="2147483647">Wal-Mart Pharmacy 9083 - (10.6)</option><option value="2147483647">Transaction Data Systems Test</option><option value="2147483647">Banner DEFAULT PHARMACY</option><option value="2147483647">Build Test 10.6</option><option value="2147483647">35char12345678912345678912345678912</option><option value="2147483647">Emdeon Test Store #23</option><option value="2147483647">Enclara Pharmacia</option><option value="2147483647">CNR EDIT PHARMACY</option><option value="2147483647">PioneerRx EScript Testing</option><option value="2147483647">Test Pharmacy</option><option value="2147483647">PJP PHARM THREE - disp</option><option value="2147483647">PJP Pharm FOUR Pacific PHR (Disp)</option><option value="2147483647">PJP FINAL PHARM ONE</option><option value="2147483647">AACE QA - Phoenixville Hospital</option><option value="2147483647">Pittsburgh Pharmacy</option><option value="2147483647">ExcelleRx Test Pharm 99999999999999</option><option value="2147483647">Madeup Pharmacy</option><option value="2147483647">RTBC Test 82001</option><option value="2147483647">pc I Demonstration Systm</option><option value="2147483647">ABC Pharmacy</option><option value="2147483647">RTBC Test 44306</option><option value="2147483647">Golden AIX</option><option value="2147483647">Walgreen Drug Store 79386</option><option value="2147483647">Nocancel Pharmacy 10.6 MU</option><option value="2147483647">Sales Support- AZ DemoLab (1962)</option><option value="2147483647">Stage Epa Portal Org</option><option value="2147483647">EMC PRESCRIPTION PHARMACY NORTH</option><option value="2147483647">RightSource 10.6 Pharmacy</option><option value="2147483647">PPI INTERFACE31</option><option value="2147483647">QA23-EF</option><option value="2147483647">QA23-PT1</option><option value="2147483647">8090 tp depr testing region</option><option value="2147483647">Rite Aid Test Store 12992</option><option value="2147483647">10.6 PPI FACILITY</option><option value="2147483647">CHTSTII</option><option value="2147483647">VeryVeryVeryVeryVeryLongClinicName1</option><option value="2147483647">Wegmans Corporate store</option><option value="2147483647">RTBC Test 55419</option> </select>
</div>
</div>
<div class="col-md-6" style="padding-left: 0px;">
<input type="hidden" name="bridge[DrugDescription]" value="Xolair 150 mg vial">
<input type="hidden" name="bridge[DrugNDC]" value="68084072211">
<div class="col-md-12 section-title">
<h4 class="box-title">BRIDGE PHARMACY PRESCRIPTION</h4>
</div>
<div class="col-md-12 form-group">
<label for="bridge_drugSigText">Sig.<sup style="color: red;">*</sup> <small>max 140 characters</small></label>
<input type="text" class="form-control requiredval" value="Inject 225 mg subcutaneously once every 2 weeks" name="bridge[DrugSigText]" required="true" id="bridge_drugSigText" placeholder="">
</div>
<!-- <div class="col-md-12 form-group">
<label for="bridge_drugPackageRefills">Package Unit <small>optional</small></label>
<input type="text" class="form-control" value="C64933" name="bridge[DrugPackageRefills]" id="bridge_drugPackageRefills" placeholder="">
</div> -->
<div class="col-md-12 form-group">
<label for="bridge_drugQuantity">Quantity<sup style="color: red;">*</sup> </label>
<input type="text" class="form-control requiredval numval" value="6" name="bridge[DrugQuantity]" required="true" id="bridge_drugQuantity" placeholder="">
</div>
<div class="col-md-12 form-group">
<label for="bridge_drugDaysSupply">Days Supply<sup style="color: red;">*</sup></label>
<input type="text" class="form-control requiredval numval" value="60" name="bridge[DrugDaysSupply]" required="true" id="bridge_drugDaysSupply" placeholder="">
</div>
<!-- <div class="col-md-12 form-group">
<label for="bridge_drugNumberOfRefills">Refills</label>
<input type="text" class="form-control numval" value="1" name="bridge[DrugNumberOfRefills]" id="bridge_drugNumberOfRefills" placeholder="">
</div>-->
<div class="col-md-12 form-group">
<label for="bridge_notesToPharmacy">Notes to Pharmacy</label>
<input type="text" class="form-control" value="" name="bridge[NotesToPharmacy]" id="bridge_notesToPharmacy" placeholder="">
</div>
<div class="col-md-12 form-group">
<label>Pharmacy Details:</label>
<div>
Phone: <br>
(NCPDP: , NPI: )
</div>
</div>
</div>
<div class="col-md-12 diagnosis_code_section">
<div class="col-md-12" style="border: 1px solid #003865;padding-top: 20px;margin-bottom: 2%;">
<label class="diagnosis_code_title">Diagnosis Codes</label>
<div class="col-md-6 form-group mt-2">
<label for="diagnosisCode" style="font-size: 12px;">Diagnosis Code 1</label>
<div>
<input type="text" class="form-control" name="diagnosisCode[]" id="diagnosisCode1" value="J4540" placeholder="Code 1" style="width: 55%;
margin-right: 4%;float: left; margin-bottom: 5px;">
</div>
</div>
<div class="col-md-6 form-group">
<div>
<label for="diagnosisCode" style="font-size: 12px;">Diagnosis Code 2</label>
<input type="hidden" name="PrimaryICDDescription" value="Moderate persistent asthma, uncomplicated">
<input type="hidden" name="SecondaryICDDescription" value="">
<input type="text" class="form-control" name="diagnosisCode[]" id="diagnosisCode2" value="" placeholder="Code 2" style="width: 55%;">
</div>
</div>
</div>
</div>
<br>
<center><button type="button" id="preview_btn" class="btn btn-block btn-danger btn-lg" style="width: 200px;">Preview Prescription</button></center>
</div>
<!-- /.row -->
</div>
<!-- /.box-body -->
</form>
</div>
</section></div>
<!-- ./wrapper -->
</body></html>