Product id: 0
<br />
Give Crohns disease the flush with SedaCrohn
<br />
$34.99
<br /><br />

<form action="confirm.php?pid=0" method="post">

<label>Quantity:<br />
<input type="text" name="qua" id="qua" />
</label><br />
<label>First name:<br />
<input type="text" name="fname" id="fname" />
</label><br />
<label>Last name:<br />
<input type="text" name="lname" id="lname" />
</label><br />
<label>Address:<br />
<input type="text" name="addr" id="addr" />
</label><br />
<label>State:<br />
<input type="text" name="state" id="state" maxlength="2" />
<br /><i>ie. MA</i><br />
</label><br />
<label>Zipcode:<br />
<input type="text" name="zip" id="zip" maxlength="5" />
</label><br /><br />
<label>Credit Card Number:<br />
<input type="text" name="ccn" id="ccn" maxlength="16" />
</label><br />
<label>Expiration date:<br />
<input type="text" name="exp" id="exp" />
</label><br />
<input type="submit" value="Continue" />
</form>