 

	<form method = "post" class="payment_form">
		<h3 data-fontsize="22" data-lineheight="28">Pay Your Bill Online</h3>
		<div style="margin-bottom: 10px;" class="fusion-one-half fusion-layout-column fusion-spacing-yes"> 
			<input type="text" class="wpcf7-form-control wpcf7-text" name="f_name" id="f_name" placeholder="Enter First Name" required>
		</div>
		<div style="margin-bottom: 10px;" class="fusion-one-half fusion-layout-column fusion-column-last fusion-spacing-yes"> 
			<input type="text" class="wpcf7-form-control wpcf7-text" name="l_name" id="l_name" placeholder="Enter Last Name" required>
		</div>
		<div style="margin-bottom: 10px;" class="fusion-one-half fusion-layout-column fusion-spacing-yes"> 
			<input type="text" class="wpcf7-form-control wpcf7-text" name="email" id="email" placeholder="Enter Email" required>
		</div>
		<div style="margin-bottom: 10px;" class="fusion-one-half fusion-layout-column fusion-column-last fusion-spacing-yes"> 
			<input type="text" class="wpcf7-form-control wpcf7-text" name="phone" id="phone" placeholder="Enter Phone" required>
		</div>
		<p style="margin-bottom: 10px;">
			<input type="text" class="wpcf7-form-control wpcf7-text" name="address" id="address" placeholder="Enter Address" required>
		</p>
		<div style="margin-bottom: 10px;" class="fusion-one-half fusion-layout-column fusion-spacing-yes"> 
			<input type="text" class="wpcf7-form-control wpcf7-text" name="city" id="city" placeholder="Enter City" required>
		</div>
		<div style="margin-bottom: 10px;" class="fusion-one-half fusion-layout-column fusion-column-last fusion-spacing-yes"> 
			<input type="text" class="wpcf7-form-control wpcf7-text" name="state" id="state" placeholder="Enter State" required>
		</div>	
		<div style="margin-bottom: 10px;" class="fusion-one-half fusion-layout-column fusion-spacing-yes"> 
			<input type="text" class="wpcf7-form-control wpcf7-text" name="country" id="country" placeholder="Enter Country" required>
		</div>
		<div style="margin-bottom: 10px;" class="fusion-one-half fusion-layout-column fusion-column-last fusion-spacing-yes"> 
			<input type="text" class="wpcf7-form-control wpcf7-text" name="zip" id="zip" placeholder="Enter Zip" required>
		</div>	
		
		<div style="margin-bottom: 10px;" class="fusion-one-half fusion-layout-column fusion-spacing-yes"> 
			<input type="text" class="wpcf7-form-control wpcf7-text" name="price" id="price" placeholder="Enter Payment Amount" required>
		</div>
		<div style="margin-bottom: 10px;" class="fusion-one-half fusion-layout-column fusion-column-last fusion-spacing-yes"> 
			<input type="text" class="wpcf7-form-control wpcf7-text" name="mdr" id="mdr" placeholder="Enter Medical Record Number" required>
		</div>	
		<p style="margin-bottom: 10px;">
			<input type="text" class="wpcf7-form-control wpcf7-text" name="desc" id="desc" placeholder="Enter Description" required>
		</p>
	    <input style="  margin-top: 10px;" class="button wpcf7-form-control wpcf7-submit" type="submit" name="payment">
	</form>	
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