+<table class="type"><tbody>
+ <tr>
+ <th>$(l10n doctor)</th>
+ <th>$(l10n dentist)</th>
+ <th>$(l10n noprescription)</th>
+ <th>$(l10n altpractition)</th>
+ </tr>
+ <tr>
+ <td class="selfpaid doctor">
+ <input type=radio name=presctype id=doctor_selfpaid value=doctor_selfpaid>
+ <label for=doctor_selfpaid>$(l10n selfpaid)</label>
+ </td>
+ <td class="selfpaid dentist">
+ <input type=radio name=presctype id=dentist_selfpaid value=dentist_selfpaid>
+ <label for=dentist_selfpaid>$(l10n selfpaid)</label>
+ </td>
+ <td class="selfpaid noprescription">
+ <input type=radio name=presctype id=noprescription_selfpaid value=noprescription_selfpaid>
+ <label for=noprescription_selfpaid>$(l10n selfpaid)</label>
+ </td>
+ <td class="selfpaid altpractition">
+ <input type=radio name=presctype id=altpractition_selfpaid value=altpractition_selfpaid>
+ <label for=altpractition_selfpaid>$(l10n selfpaid)</label>
+ </td>
+ </tr>
+ <tr>
+ <td class="private doctor">
+ <input type=radio name=presctype id=doctor_private value=doctor_private>
+ <label for=doctor_private>$(l10n private)</label>
+ </td>
+ <td class="private dentist">
+ <input type=radio name=presctype id=dentist_private value=dentist_private>
+ <label for=dentist_private>$(l10n private)</label>
+ </td>
+ <td class="private noprescription">
+ </td>
+ <td class="private altpractition">
+ <input type=radio name=presctype id=altpractition_private value=altpractition_private>
+ <label for=altpractition_private>$(l10n private)</label>
+ </td>
+ </tr>
+ <tr>
+ <td class="compulsory doctor">
+ <input type=radio name=presctype id=doctor_compulsory value=doctor_compulsory>
+ <label for=doctor_compulsory>$(l10n compulsory)</label>
+ </td>
+ <td class="compulsory dentist">
+ <input type=radio name=presctype id=dentist_compulsory value=dentist_compulsory>
+ <label for=dentist_compulsory>$(l10n compulsory)</label>
+ </td>
+ <td class="compulsory noprescription">
+ </td>
+ <td class="compulsory altpractition">
+ </td>
+ </tr>
+</tbody></table>
+