<div class="row">
    <div class="col-sm-6">
        [text* your-name placeholder "Name"]
    </div>
    <div class="col-sm-6">
        [text* phone-number placeholder "Phone Number"]
    </div>
    <div class="col-sm-6">
        [text* your-date placeholder "dd/mm/yyyy"]
    </div>
    <div class="col-sm-6">
        [text* your-time placeholder "Time"]
    </div>
    <div class="col-sm-6">
        [email* your-email placeholder "Enter Email"]
    </div>
    <div class="col-sm-6 ">
        [select select-department "Select Departments" "Hematology" "Orthopedics" "Cardiology" "Pediatric" "Medicine"]
    </div>
    <div class="col-md-12 down-btn-area">
           [textarea your-message placeholder "Your Message"]
           [submit "Make Appointment"]
    </div>
</div>