</div> <div class="attorney_row"> <div class="attorney_right"> <label>City</label> <input type="text" name="user_city" value="<?php if (isset($_POST['user_city'])) { echo $_POST['user_city']; } ?> " id=""/> <span class="error validation"></span> </div> <div class="attorney_left"> <label>State</label> <?php $temp_profile->GetState(); ?> <span class="error validation"></span> </div> </div> <div class="attorney_row"> <div class="attorney_left"> <label>Zip Code</label> <input type="text" name="zip_code" value="<?php if (isset($_POST['zip_code'])) { echo $_POST['zip_code']; } ?> " id=""/> <span class="error validation"></span> </div>
</div> <div class="attorney_row"> <label>Address</label> <input type="text" required="required" name="user_address" id=""/> <span class="error validation"></span> </div> <div class="attorney_row"> <div class="attorney_right"> <label>City</label> <input type="text" required="required" name="user_city" id=""/> <span class="error validation"></span> </div> <div class="attorney_left"> <label>State</label> <?php $meshedform->GetState(); ?> <span class="error validation"></span> </div> </div> <div class="attorney_row"> <div class="attorney_left"> <label>Zip Code</label> <input type="text" required="required" name="zip_code" id=""/> <span class="error validation"></span> </div> <div class="attorney_right"> <label>Preferred Choice of Doctor *Not Requried</label> <input type="text" required="required" name="doctor_name" id=""/> <span class="error validation"></span> </div>