I need someone to make the lower portion of my PHP form match the attached word document. I need to replace everything under the row on the PHP form that says "if your injuries could be due to an auto accident, please fill out this section" with the fields from the "mechanism of injury" word doc. The fields need to have unique short names.
please leave the captcha stuff and the "treatment authorization" at the bottom of the form. Let me know if you have any questions.
## Deliverables
1) Complete and fully-functional working program(s) in executable form as well as complete source code of all work done.
2) Deliverables must be in ready-to-run condition, as follows (depending on the nature of the deliverables):
a) For web sites or other server-side deliverables intended to only ever exist in one place in the Buyer's environment--Deliverables must be installed by the Seller in ready-to-run condition in the Buyer's environment.
b) For all others including desktop software or software the buyer intends to distribute: A software installation package that will install the software in ready-to-run condition on the platform(s) specified in this bid request.
3) All deliverables will be considered "work made for hire" under U.S. Copyright law. Buyer will receive exclusive and complete copyrights to all work purchased. (No GPL, GNU, 3rd party components, etc. unless all copyright ramifications are explained AND AGREED TO by the buyer on the site per the coder's Seller Legal Agreement).
## Platform
PHP page