<input type="hidden" name="cmd" value="_s-xclick">

<input type="hidden" name="hosted_button_id" value="CEYT9USTNEV9W">

<table>

<tr><td><input type="hidden" name="on0" value="Patient Code">Patient Code</td></tr><tr><td><input type="text" name="os0" maxlength="200"></td></tr>

<tr><td><input type="hidden" name="on1" value="Invoice Number">Invoice Number</td></tr><tr><td><input type="text" name="os1" maxlength="200"></td></tr>

</table>

<input type="image" src="https://www.paypalobjects.com/en_US/i/btn/btn_paynowCC_LG.gif" border="0" name="submit" alt="PayPal - The safer, easier way to pay online!">

<img alt="" border="0" src="https://www.paypalobjects.com/en_US/i/scr/pixel.gif" width="1" height="1">

</form>