<br />
   <center>
   <form action="index.php?action=store-list" method="post">
   <table cellpadding=2 cellspacing=0 bgcolor="#cccccc">
   <tr><th colspan = 2 bgcolor = "#5B69A6" > Patient - Insert </th></tr> 
   <tr><td>Account No</td>
       <td><input type="listname" name="listname" size=20 maxlength=20></td>
   </tr>
   <tr>
    <td>First Name:</td>
       <td><input type="listname" name="listname" size=20 maxlength=20></td>
   </tr>
   <tr>
    <td>Surname:</td>
       <td><input type="listname" name="listname" size=20 maxlength=20></td>
   </tr>
   <tr>
    <td>ID Number:</td>
       <td><input type="listname" name="listname" size=20 maxlength=20></td>
   </tr>
   <tr>
    <td>Birthday:</td>
       <td><input type="listname" name="listname" size=20 maxlength=20></td>
   </tr>
   <tr>
    <td>Medical Aid:</td>
       <td><input type="listname" name="listname" size=20 maxlength=20></td>
   </tr>
   <tr>
    <td>List Name:</td>
       <td><input type="listname" name="listname" size=20 maxlength=20></td>
   </tr>
   <tr>
    <td>List Name:</td>
       <td><input type="listname" name="listname" size=20 maxlength=20></td>
   </tr>
   <tr>
    <td>List Name:</td>
       <td><input type="listname" name="listname" size=20 maxlength=20></td>
   </tr>
   <tr>
    <td>List Name:</td>
       <td><input type="listname" name="listname" size=20 maxlength=20></td>
   </tr>
   <tr>
    <td>List Name:</td>
       <td><input type="listname" name="listname" size=20 maxlength=20></td>
   </tr>
   <tr>
    <td>List Name:</td>
       <td><input type="listname" name="listname" size=20 maxlength=20></td>
   </tr>
   <tr><td colspan = 2>&nbsp;</td></tr>
   <tr><td colspan=2 align="center"><?php display_form_button('save-list'); ?>
   </td></tr>
   </table>
   </center>
<br />