[ SNIP ]

    <?php
    $this->setShowAddressFields(true);
    if($this->getShowAddressFields()): ?>
        <div class="fieldset">
            <input type="hidden" name="create_address" value="1" />
            <h2 class="legend"><?php echo $this->__('Billing Address Information') ?></h2>
            <ul class="form-list">
                <li class="fields">
                    <div class="field" id="businessName">
                        <label for="company" class="required"><?php echo $this->__('Business Name') ?> <em>*</em></label>
                        <div class="input-box">
                            <input type="text" name="company" id="company" value="<?php echo $this->htmlEscape($this->getFormData()->getCompany()) ?>" title="<?php echo $this->__('Company') ?>" class="input-text required-entry" />
                        </div>
                    </div>
                    <div class="field">
                        <label for="telephone" class="required"><?php echo $this->__('Telephone') ?> <em>*</em></label>
                        <div class="input-box">
                            <input type="text" name="telephone" id="telephone" value="<?php echo $this->htmlEscape($this->getFormData()->getTelephone()) ?>" title="<?php echo $this->__('Telephone') ?>" class="input-text required-entry" />
                        </div>
                    </div>
                </li>
                <li class="wide">
                    <label for="street_1" class="required"><?php echo $this->__('Street Address') ?> <em>*</em></label>
                    <div class="input-box" style="clear: both;">
                        <input type="text" name="street[]" value="<?php echo $this->htmlEscape($this->getFormData()->getStreet(1)) ?>" title="<?php echo $this->__('Street Address') ?>" id="street_1" class="input-text required-entry" />
                    </div>
                </li>
            <?php for ($_i=2, $_n=$this->helper('customer/address')->getStreetLines(); $_i<=$_n; $_i++): ?>
                <li class="wide">
                    <div class="input-box">
                        <input type="text" name="street[]" value="<?php echo $this->htmlEscape($this->getFormData()->getStreet($_i)) ?>" title="<?php echo $this->__('Street Address %s', $_i) ?>" id="street_<?php echo $_i?>" class="input-text" />
                    </div>
                </li>
            <?php endfor ?>
                <li class="fields">
                    <div class="field">
                        <label for="city" class="required"><?php echo $this->__('City') ?> <em>*</em></label>
                        <div class="input-box">
                            <input type="text" name="city" value="<?php echo $this->htmlEscape($this->getFormData()->getCity()) ?>" title="<?php echo $this->__('City') ?>" class="input-text required-entry" id="city" />
                        </div>
                    </div>
                    <div class="field">
                        <label for="region_id" class="required"><?php echo $this->__('State/Province') ?> <em>*</em></label>
                        <div class="input-box">
                            <select id="region_id" name="region_id" title="<?php echo $this->__('State/Province') ?>" class="validate-select" style="display:none;">
                                <option value=""><?php echo $this->__('Please select region, state or province') ?></option>
                            </select>
                            <script type="text/javascript">
                            //<![CDATA[
                                $('region_id').setAttribute('defaultValue', "<?php echo $this->getFormData()->getRegionId() ?>");
                            //]]>
                            </script>
                            <input type="text" id="region" name="region" value="<?php echo $this->htmlEscape($this->getRegion()) ?>" title="<?php echo $this->__('State/Province') ?>" class="input-text" style="display:none;" />
                        </div>
                    </div>
                </li>
                <li class="fields">
                    <div class="field">
                        <label for="zip" class="required"><?php echo $this->__('Zip/Postal Code') ?> <em>*</em></label>
                        <div class="input-box">
                            <input type="text" name="postcode" value="<?php echo $this->htmlEscape($this->getFormData()->getPostcode()) ?>" title="<?php echo $this->__('Zip/Postal Code') ?>" id="zip" class="input-text validate-zip-international required-entry" />
                        </div>
                    </div>
                    <div class="field">
                        <label for="country" class="required"><?php echo $this->__('Country') ?> <em>*</em></label>
                        <div class="input-box">
                            <?php echo $this->getCountryHtmlSelect() ?>
                        </div>
                    </div>
                </li>
            </ul>
            <input type="hidden" name="default_billing" value="1" />
            <input type="hidden" name="default_shipping" value="1" />
        </div>

        <!-- Shipping address -->

        <div class="fieldset">
            <input type="hidden" name="create_shipping_address" value="0" />
            <h2 class="legend"><?php echo $this->__('Shipping Address Information') ?></h2>

            <div id="shipping_profAddressInstruction">Samples will only be sent to registered clinic addresses.</div>

            <ul class="form-list">
                <li class="fields">
                    <div class="field">
                        <div class="input-box">
                            <label for="shipping_same_as_billing">
                                <input id="shipping_same_as_billing" type="checkbox" checked="checked"/>

                                <?php echo $this->__('Same as Billing Address') ?>
                            </label>
                        </div>
                    </div>
                </li>
            </ul>

            <div id="shipping_address_fields" style="display: none;">
                <ul class="form-list">
                    <li class="fields">
                        <div class="field" id="shipping_businessName">
                            <label for="shipping_company" class="required"><?php echo $this->__('Business Name') ?> <em>*</em></label>
                            <div class="input-box">
                                <input type="text" name="shipping_company" id="shipping_company" value="<?php echo $this->htmlEscape($this->getFormData()->getShippingCompany()) ?>" title="<?php echo $this->__('Company') ?>" class="input-text required-entry" />
                            </div>
                        </div>
                        <div class="field">
                            <label for="shipping_telephone" class="required"><?php echo $this->__('Telephone') ?> <em>*</em></label>
                            <div class="input-box">
                                <input type="text" name="shipping_telephone" id="shipping_telephone" value="<?php echo $this->htmlEscape($this->getFormData()->getShippingTelephone()) ?>" title="<?php echo $this->__('Telephone') ?>" class="input-text required-entry" />
                            </div>
                        </div>
                    </li>
                    <li class="wide">
                        <label for="shipping_street_1" class="required"><?php echo $this->__('Street Address') ?> <em>*</em></label>
                        <div class="input-box" style="clear: both;">
                            <input type="text" name="shipping_street[]" value="<?php echo $this->htmlEscape($this->getFormData()->getShippingStreet(1)) ?>" title="<?php echo $this->__('Street Address') ?>" id="shipping_street_1" class="input-text required-entry" />
                        </div>
                    </li>
                <?php for ($_i=2, $_n=$this->helper('customer/address')->getStreetLines(); $_i<=$_n; $_i++): ?>
                    <li class="wide">
                        <div class="input-box">
                            <input type="text" name="shipping_street[]" value="<?php echo $this->htmlEscape($this->getFormData()->getShippingStreet($_i)) ?>" title="<?php echo $this->__('Street Address %s', $_i) ?>" id="shipping_street_<?php echo $_i?>" class="input-text" />
                        </div>
                    </li>
                <?php endfor ?>
                    <li class="fields">
                        <div class="field">
                            <label for="shipping_city" class="required"><?php echo $this->__('City') ?> <em>*</em></label>
                            <div class="input-box">
                                <input type="text" name="shipping_city" value="<?php echo $this->htmlEscape($this->getFormData()->getShippingCity()) ?>" title="<?php echo $this->__('City') ?>" class="input-text required-entry" id="shipping_city" />
                            </div>
                        </div>
                        <div class="field">
                            <label for="shipping_region_id" class="required"><?php echo $this->__('State/Province') ?> <em>*</em></label>
                            <div class="input-box">
                                <select id="shipping_region_id" name="shipping_region_id" title="<?php echo $this->__('State/Province') ?>" class="validate-select" style="display:none;">
                                    <option value=""><?php echo $this->__('Please select region, state or province') ?></option>
                                </select>
                                <script type="text/javascript">
                                //<![CDATA[
                                    $('shipping_region_id').setAttribute('defaultValue', "<?php echo $this->getFormData()->getShippingRegionId() ?>");
                                //]]>
                                </script>
                                <input type="text" id="shipping_region" name="shipping_region" value="<?php echo $this->htmlEscape($this->getRegion()) ?>" title="<?php echo $this->__('State/Province') ?>" class="input-text" style="display:none;" />
                            </div>
                        </div>
                    </li>
                    <li class="fields">
                        <div class="field">
                            <label for="shipping_zip" class="required"><?php echo $this->__('Zip/Postal Code') ?> <em>*</em></label>
                            <div class="input-box">
                                <input type="text" name="shipping_postcode" value="<?php echo $this->htmlEscape($this->getFormData()->getShippingPostcode()) ?>" title="<?php echo $this->__('Zip/Postal Code') ?>" id="shipping_zip" class="input-text validate-zip-international required-entry" />
                            </div>
                        </div>
                        <div class="field">
                            <label for="shipping_country" class="required"><?php echo $this->__('Country') ?> <em>*</em></label>
                            <div class="input-box">
                                <?php echo $this->getCountryHtmlSelect(null, 'shipping_country_id', 'shipping_country_id') ?>
                            </div>
                        </div>
                    </li>
                </ul>
                <input type="hidden" name="shipping_default_billing"  value="0" />
                <input type="hidden" name="shipping_default_shipping" value="1" />
            </div>
        </div>
    <?php endif; ?>
        <div class="fieldset last">
            <h2 class="legend"><?php echo $this->__('Login Information') ?></h2>
            <ul class="form-list">
                <li class="fields">
                    <div class="field">
                        <label for="password" class="required"><?php echo $this->__('Password') ?> <em>*</em></label>
                        <div class="input-box">
                            <input type="password" name="password" id="password" title="<?php echo $this->__('Password') ?>" class="input-text required-entry validate-password" />
                        </div>
                    </div>
                    <div class="field">
                        <label for="confirmation" class="required"><?php echo $this->__('Confirm Password') ?> <em>*</em></label>
                        <div class="input-box">
                            <input type="password" name="confirmation" title="<?php echo $this->__('Confirm Password') ?>" id="confirmation" class="input-text required-entry validate-cpassword" />
                        </div>
                    </div>
                </li>
            </ul>
        </div>
        <input type="hidden" name="amcustomerattr[sample_selection]" value="0" id="sample_selection" />
        <div class="buttons-set">
            <p class="required"><?php echo $this->__('* Required Fields') ?></p>
            <p class="back-link"><a href="<?php echo $this->escapeUrl($this->getBackUrl()) ?>" class="back-link"><small>&laquo; </small><?php echo $this->__('Back') ?></a></p>
            <button type="submit" title="<?php echo $this->__('Submit') ?>"></button>
        </div>
    </form>
    </div>
    <script type="text/javascript">
    //<![CDATA[
        var dataForm = new VarienForm('form-validate', true);
        <?php if($this->getShowAddressFields()): ?>
        new RegionUpdater('country',          'region',          'region_id', <?php echo $this->helper('directory')->getRegionJson() ?>, undefined, 'zip');
        new RegionUpdater('country', 'shipping_region', 'shipping_region_id', <?php echo $this->helper('directory')->getRegionJson() ?>, undefined, 'zip');
        <?php endif; ?>

        (function($) {
            $('#shipping_same_as_billing').change(function() {
                if ( $(this).is(':checked') ) {
                    $('#shipping_address_fields').hide();

                    $('input[name=create_shipping_address]').val('0');
                    $('input[name=default_shipping]'       ).val('1');
                } else {
                    $('#shipping_address_fields').show();

                    $('input[name=create_shipping_address]').val('1');
                    $('input[name=default_shipping]'       ).val('0');
                }
            });
        }(jQuery));
    //]]>
    </script>