</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>
