{php}html_header_show();{/php}
{literal} {/literal}
{xl t='Starting Date'}
{html_select_date start_year="-10" end_year="+5" time=$prescription->start_date prefix="start_date_"}
{xl t='Provider'}
{html_options name="provider_id" options=$prescription->provider->utility_provider_array() selected=$prescription->provider->get_id()}
{xl t='Drug Finder'}
{if $DRUG_ARRAY_VALUES}
{html_options values=$DRUG_ARRAY_VALUES output=$DRUG_ARRAY_OUTPUT}
{/if}
{xl t='Drug' }
{xl t='Qty' }
{xl t='Size' }
{xl t='Units'}
{xl t='Take' }
{xl t='Form' }
{xl t='Route'}
{xl t='Intvl'}
{xl t='Refs' }
{xl t='Per' }
{xl t='Sub' }
[{xl t='Add Row'}]
{xl t='Notes'}
{$prescription->note}
{xl t='Add to Medication List'}
{html_radios name="medication" options=$prescription->medication_array selected=$prescription->medication}
{literal}