<link href="//maxcdn.bootstrapcdn.com/bootstrap/3.3.0/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css"> <script src="//maxcdn.bootstrapcdn.com/bootstrap/3.3.0/js/bootstrap.min.js"></script> <script src="//code.jquery.com/jquery-1.11.1.min.js"></script> <!------ Include the above in your HEAD tag ----------> <form class="form-horizontal" role="form"> <div class="col-md-12"> <div class="form-group"> <div class="col-md-6"> <label for="inputStatus" class="control-label">Apellidos:</label> <input class="form-control" name="num_pedido" type="text" placeholder="Apellidos:" /> </div> <div class="col-md-6"> <label for="inputStatus" class="control-label">Nombres</label> <input class="form-control" name="num_pedido" type="text" placeholder="Nombres:" /> </div> </div> </div> <div class="col-md-12"> <div class="form-group"> <div class="col-md-3"> <label for="inputStatus" class="control-label">Cedula:</label> <input class="form-control" name="num_pedido" type="text" placeholder="Cedula:" /> </div> <div class="col-md-3"> <label for="inputStatus" class="control-label">Celular:</label> <input class="form-control" name="num_pedido" type="text" placeholder="Celular:" /> </div> <div class="col-md-3"> <label for="inputStatus" class="control-label">Semana::</label> <select class="form-control" required=""> <option value="Fertilizacion">Fertilización</option> <option value="Implantacion">Implantación</option> <option value="Semana 4">Semana 4</option> <option value="Semana 5">Semana 5</option> <option value="Semana 6">Semana 6</option> <option value="Semana 7">Semana 7</option> <option value="Semana 8">Semana 8</option> <option value="Semana 9">Semana 9</option> <option value="Semana 10">Semana 10</option> <option value="Semana 11">Semana 11</option> <option value="Semana 12">Semana 12</option> <option value="Semana 13">Semana 13</option> <option value="Semana 14">Semana 14</option> <option value="Semana 15">Semana 15</option> <option value="Semana 16">Semana 16</option> <option value="Semana 17">Semana 17</option> <option value="Semana 18">Semana 18</option> <option value="Semana 19">Semana 19</option> <option value="Semana 20">Semana 20</option> <option value="Semana 21">Semana 21</option> <option value="Semana 22">Semana 22</option> <option value="Semana 23">Semana 23</option> <option value="Semana 24">Semana 24</option> <option value="Semana 25">Semana 25</option> <option value="Semana 26">Semana 26</option> <option value="Semana 27">Semana 27</option> <option value="Semana 28">Semana 28</option> <option value="Semana 29">Semana 29</option> <option value="Semana 30">Semana 30</option> <option value="Semana 31">Semana 31</option> <option value="Semana 32">Semana 32</option> <option value="Semana 33">Semana 33</option> <option value="Semana 34">Semana 34</option> <option value="Semana 35">Semana 35</option> <option value="Semana 36">Semana 36</option> <option value="Semana 37">Semana 37</option> <option value="Semana 38">Semana 38</option> <option value="Semana 39">Semana 39</option> <option value="Semana 40">Semana 40</option> </select> </div> <div class="col-md-3"> <label for="inputStatus" class="control-label">Dr@. del paciente:</label> <input class="form-control" name="num_pedido" type="text" placeholder="Dr@.:" /> </div> </div> </div> <div class="col-md-12"> <div class="form-group"> <div class="col-md-3"> <label for="inputStatus" class="control-label">Tipo de Parto:</label> <select class="form-control"> <option value="">Selleccionar... </option> <option value="Parto Normal">Parto Normal </option> <option value="Parto por Cesarea"> Parto por Cesarea </option> </select> </div> <div class="col-md-2"> <label for="inputStatus" class="control-label">Fecha Maxima Estimada::</label> <input class="form-control" name="num_pedido" type="date" /> </div> <div class="col-md-4"> <label for="inputStatus" class="control-label">E-mail:</label> <input class="form-control" name="num_pedido" type="text" placeholder="E-mail:" /> </div> <div class="col-md-3"> <label for="inputStatus" class="control-label">Forma de Pago::</label> <select class="form-control"> <option value="">Selleccionar... </option> <option value="Efectivo">Efectivo </option> <option value="Seguro"> Seguro </option> <option value="Tarjeta de Credito">Tarjeta de Credito </option> <option value="Cheque"> Cheque Certificado </option> </select> </div> </div> </div> <div class="col-md-12"> <button type="button" class="btn btn-primary btn-block"><b>Registrar</b></button> </div> </form>