{"id":1886,"date":"2018-04-27T19:49:26","date_gmt":"2018-04-27T23:49:26","guid":{"rendered":"http:\/\/localhost7\/?page_id=1886"},"modified":"2020-06-06T22:23:13","modified_gmt":"2020-06-07T02:23:13","slug":"refill","status":"publish","type":"page","link":"https:\/\/surlangpharmacy.ca\/services\/prescriptions\/refill\/","title":{"rendered":"Prescription Refill"},"content":{"rendered":"<h2>Prescription Refill Form<\/h2>\n<p>Complete the form below. It will be sent to our pharmacy staff who will use the information provided to confirm, and refill your prescription for you.<\/p>\n<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_unknown gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_4' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_4'  action='\/wp-json\/wp\/v2\/pages\/1886' data-formid='4' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_4' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_4_7\" class=\"gfield gfield--type-name gf_left_half gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_7\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_4_7'>\n                            \n                            <span id='input_4_7_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_7.3' id='input_4_7_3' value=''   aria-required='true'   placeholder='Name'  \/>\n                                                    <label for='input_4_7_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/li><li id=\"field_4_17\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_17\" ><label class='gfield_label gform-field-label' for='input_4_17'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_17' id='input_4_17' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='Date of birth' aria-describedby=\"input_4_17_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_4_17_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_17' class='gform_hidden' value='https:\/\/surlangpharmacy.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_8\" class=\"gfield gfield--type-phone gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_8\" ><label class='gfield_label gform-field-label' for='input_4_8'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_4_8' type='tel' value='' class='medium'  placeholder='Phone Number' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_11\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_11\" ><label class='gfield_label gform-field-label' for='input_4_11'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_11' id='input_4_11' type='email' value='' class='medium'   placeholder='Email ' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_4_11\" \/>\n                        <\/div><div class='gfield_description' id='gfield_description_4_11'><em>Note: If you do not receive an automated e-mail message within 24-hours to confirm your on-line prescription refill(s) request, please phone 604-533-1041 for personal assistance.<\/em><\/div><\/li><li id=\"field_4_6\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_6\" ><h2 class=\"gsection_title\">Your Prescriptions<\/h2><div class='gsection_description' id='gfield_description_4_6'>You may include up to six prescriptions.<\/div><\/li><li id=\"field_4_41\" class=\"gfield gfield--type-html rx-form-note gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_41\" ><div class=\"form-instructions\"><h4>Instructions<\/h4><ul><li>You may include up to six prescriptions.<\/li><li>You must include a Medication Description <strong>OR<\/strong> Prescription Number.<\/li><li>If you use a prescription number, please make sure it's the <strong><em>most recent<\/em><\/strong> prescription number.<\/ul><\/div><\/li><li id=\"field_4_36\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_36\" ><label class='gfield_label gform-field-label' for='input_4_36'>How Many Prescriptions Would You Like Us To Refill?<\/label><div class='ginput_container ginput_container_select'><select name='input_36' id='input_4_36' class='small gfield_select'     aria-invalid=\"false\" ><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><\/select><\/div><\/li><li id=\"field_4_40\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_above hidden_label gfield_visibility_visible\"  data-js-reload=\"field_4_40\" ><label class='gfield_label gform-field-label' for='input_4_40'>Prescription 1<\/label><div class='gfield_description' id='gfield_description_4_40'>1. Medication Description <strong>OR<\/strong> Prescription number<\/div><div class='ginput_container ginput_container_text'><input name='input_40' id='input_4_40' type='text' value='' class='medium'  aria-describedby=\"gfield_description_4_40\"  placeholder='Description OR Prescription Number'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_42\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_above hidden_label gfield_visibility_visible\"  data-js-reload=\"field_4_42\" ><label class='gfield_label gform-field-label' for='input_4_42'>Prescription 2<\/label><div class='gfield_description' id='gfield_description_4_42'>2. Medication Description <strong>OR<\/strong> Prescription number<\/div><div class='ginput_container ginput_container_text'><input name='input_42' id='input_4_42' type='text' value='' class='medium'  aria-describedby=\"gfield_description_4_42\"  placeholder='Description OR Prescription Number'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_43\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_above hidden_label gfield_visibility_visible\"  data-js-reload=\"field_4_43\" ><label class='gfield_label gform-field-label' for='input_4_43'>Prescription 3<\/label><div class='gfield_description' id='gfield_description_4_43'>3. Medication Description <strong>OR<\/strong> Prescription number<\/div><div class='ginput_container ginput_container_text'><input name='input_43' id='input_4_43' type='text' value='' class='medium'  aria-describedby=\"gfield_description_4_43\"  placeholder='Description OR Prescription Number'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_44\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_above hidden_label gfield_visibility_visible\"  data-js-reload=\"field_4_44\" ><label class='gfield_label gform-field-label' for='input_4_44'>Prescription 4<\/label><div class='gfield_description' id='gfield_description_4_44'>4. Medication Description <strong>OR<\/strong> Prescription number<\/div><div class='ginput_container ginput_container_text'><input name='input_44' id='input_4_44' type='text' value='' class='medium'  aria-describedby=\"gfield_description_4_44\"  placeholder='Description OR Prescription Number'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_45\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_above hidden_label gfield_visibility_visible\"  data-js-reload=\"field_4_45\" ><label class='gfield_label gform-field-label' for='input_4_45'>Prescription 5<\/label><div class='gfield_description' id='gfield_description_4_45'>5. Medication Description <strong>OR<\/strong> Prescription number<\/div><div class='ginput_container ginput_container_text'><input name='input_45' id='input_4_45' type='text' value='' class='medium'  aria-describedby=\"gfield_description_4_45\"  placeholder='Description OR Prescription Number'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_46\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_above hidden_label gfield_visibility_visible\"  data-js-reload=\"field_4_46\" ><label class='gfield_label gform-field-label' for='input_4_46'>Prescription 6<\/label><div class='gfield_description' id='gfield_description_4_46'>6. Medication Description <strong>OR<\/strong> Prescription number<\/div><div class='ginput_container ginput_container_text'><input name='input_46' id='input_4_46' type='text' value='' class='medium'  aria-describedby=\"gfield_description_4_46\"  placeholder='Description OR Prescription Number'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_35\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_35\" ><h2 class=\"gsection_title\">Pick Up &amp; Delivery<\/h2><\/li><li id=\"field_4_38\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_38\" ><label class='gfield_label gform-field-label' >Select One<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_38'>\n\t\t\t<li class='gchoice gchoice_4_38_0'>\n\t\t\t\t<input name='input_38' type='radio' value='I will pick up my prescription'  id='choice_4_38_0'    \/>\n\t\t\t\t<label for='choice_4_38_0' id='label_4_38_0' class='gform-field-label gform-field-label--type-inline'>I will pick up my prescription<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_38_1'>\n\t\t\t\t<input name='input_38' type='radio' value='I would like my prescription delivered. (I understand there may be a reasonable delivery charge).'  id='choice_4_38_1'    \/>\n\t\t\t\t<label for='choice_4_38_1' id='label_4_38_1' class='gform-field-label gform-field-label--type-inline'>I would like my prescription delivered. (I understand there may be a reasonable delivery charge).<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_18\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_4_18\" ><label class='gfield_label gform-field-label' for='input_4_18'>Prescription Pick-Up Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_4_18'>Please let us know when you would like to pick up this prescription at our location. (This is required).<\/div><div class='ginput_container ginput_container_date'>\n                            <input name='input_18' id='input_4_18' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_18_date_format gfield_description_4_18\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_4_18_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_18' class='gform_hidden' value='https:\/\/surlangpharmacy.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_39\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_39\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_zip ginput_container_address gform-grid-row' id='input_4_39' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_39_1_container' >\n                                        <input type='text' name='input_39.1' id='input_4_39_1' value=''    aria-required='false'    \/>\n                                        <label for='input_4_39_1' id='input_4_39_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_4_39_3_container' >\n                                    <input type='text' name='input_39.3' id='input_4_39_3' value=''    aria-required='false'    \/>\n                                    <label for='input_4_39_3' id='input_4_39_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_39.4' id='input_4_39_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_4_39_5_container' >\n                                    <input type='text' name='input_39.5' id='input_4_39_5' value=''    aria-required='false'    \/>\n                                    <label for='input_4_39_5' id='input_4_39_5_label' class='gform-field-label gform-field-label--type-sub '>Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_39.6' id='input_4_39_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_4_15\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_4_15\" ><label class='gfield_label gform-field-label' for='input_4_15'>Special Instructions<\/label><div class='gfield_description' id='gfield_description_4_15'>Use this field to include any extra details you feel we may need to know when filling your prescription.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_15' id='input_4_15' class='textarea medium'  aria-describedby=\"gfield_description_4_15\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_4' class='gform_button button' value='Send Refill Request'  onclick='if(window[\"gf_submitting_4\"]){return false;}  if( !jQuery(\"#gform_4\")[0].checkValidity || jQuery(\"#gform_4\")[0].checkValidity()){window[\"gf_submitting_4\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_4\"]){return false;} if( !jQuery(\"#gform_4\")[0].checkValidity || jQuery(\"#gform_4\")[0].checkValidity()){window[\"gf_submitting_4\"]=true;}  jQuery(\"#gform_4\").trigger(\"submit\",[true]); 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