<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 ----------> <div class="container"> <div class="row"> <form class="form-horizontal"> <fieldset> <!-- Form Name --> <legend>Your Information</legend> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="textinput">Your Full Name:</label> <div class="col-md-4"> <input id="textinput" name="textinput" type="text" placeholder="placeholder" class="form-control input-md"> <span class="help-block">help</span> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="textinput">Phone:</label> <div class="col-md-4"> <input id="textinput" name="textinput" type="text" placeholder="placeholder" class="form-control input-md"> <span class="help-block">help</span> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="textinput">Email:</label> <div class="col-md-4"> <input id="textinput" name="textinput" type="text" placeholder="placeholder" class="form-control input-md"> <span class="help-block">help</span> </div> </div> </fieldset> </form> </div> <div class="row"> <form class="form-horizontal"> <fieldset> <!-- Form Name --> <legend>Client Information</legend> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="textinput">Date of Accident</label> <div class="col-md-4"> <input id="textinput" name="textinput" type="text" placeholder="placeholder" class="form-control input-md"> <span class="help-block">help</span> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="textinput">Full Name</label> <div class="col-md-4"> <input id="textinput" name="textinput" type="text" placeholder="placeholder" class="form-control input-md"> <span class="help-block">help</span> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="textinput">SSN:</label> <div class="col-md-4"> <input id="textinput" name="textinput" type="text" placeholder="placeholder" class="form-control input-md"> <span class="help-block">help</span> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="textinput">Date of Birth:</label> <div class="col-md-4"> <input id="textinput" name="textinput" type="text" placeholder="placeholder" class="form-control input-md"> <span class="help-block">help</span> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="textinput">File Number:</label> <div class="col-md-4"> <input id="textinput" name="textinput" type="text" placeholder="placeholder" class="form-control input-md"> <span class="help-block">help</span> </div> </div> </fieldset> </form> <div class="row"> <form class="form-horizontal"> <fieldset> <!-- Form Name --> <legend>Client Status</legend> <!-- Prepended checkbox --> <div class="form-group"> <label class="col-md-4 control-label" for="prependedcheckbox"></label> <div class="col-md-4"> <div class="input-group"> <span class="input-group-addon"> <input type="checkbox"> </span> <input id="prependedcheckbox" name="prependedcheckbox" class="form-control" type="text" placeholder="Existing Client"> </div> <p class="help-block">Specify records to obtain</p> </div> </div> <!-- Prepended checkbox --> <div class="form-group"> <label class="col-md-4 control-label" for="prependedcheckbox"></label> <div class="col-md-4"> <div class="input-group"> <span class="input-group-addon"> <input type="checkbox"> </span> <input id="prependedcheckbox" name="prependedcheckbox" class="form-control" type="text" placeholder="New Client (All Records)"> </div> <p class="help-block">Patient summary at 60 and 120 days</p> </div> </div> </fieldset> </form> </div> <div class="row"> <table class="table"> <thead> <tr> <th> Health Service </th> <th> Medical </th> <th> Billing </th> </tr> </thead> <tbody> <tr> <td> Hospital/ER: </td> <td> <input type="checkbox" name="checkboxes" id="checkboxes-0" value="1"> </td> <td> <input type="checkbox" name="checkboxes" id="checkboxes-0" value="1"> </td> </tr> <tr> <td> Therapy: </td> <td> <input type="checkbox" name="checkboxes" id="checkboxes-0" value="1"> </td> <td> <input type="checkbox" name="checkboxes" id="checkboxes-0" value="1"> </td> </tr> <tr> <td> Diagnostic: </td> <td> <input type="checkbox" name="checkboxes" id="checkboxes-0" value="1"> </td> <td> <input type="checkbox" name="checkboxes" id="checkboxes-0" value="1"> </td> </tr> <tr> <td> Orthopedic: </td> <td> <input type="checkbox" name="checkboxes" id="checkboxes-0" value="1"> </td> <td> <input type="checkbox" name="checkboxes" id="checkboxes-0" value="1"> </td> </tr> <tr> <td> Neurologist: </td> <td> <input type="checkbox" name="checkboxes" id="checkboxes-0" value="1"> </td> <td> <input type="checkbox" name="checkboxes" id="checkboxes-0" value="1"> </td> </tr> <tr> <td> Other: </td> <td> <input type="checkbox" name="checkboxes" id="checkboxes-0" value="1"> </td> <td> <input type="checkbox" name="checkboxes" id="checkboxes-0" value="1"> </td> </tr> <tr> <td> Other: </td> <td> <input type="checkbox" name="checkboxes" id="checkboxes-0" value="1"> </td> <td> <input type="checkbox" name="checkboxes" id="checkboxes-0" value="1"> </td> </tr> <tr> <td> Patient Summary 60 days </td> <td> <input type="checkbox" name="checkboxes" id="checkboxes-0" value="1"> </td> <td> <input type="checkbox" name="checkboxes" id="checkboxes-0" value="1"> </td> </tr> <tr> <td> Patient Summary 120 days </td> <td> <input type="checkbox" name="checkboxes" id="checkboxes-0" value="1"> </td> <td> <input type="checkbox" name="checkboxes" id="checkboxes-0" value="1"> </td> </tr> <tr> <td> Final Package with all records and bills sorted </td> <td> <input type="checkbox" name="checkboxes" id="checkboxes-0" value="1"> </td> <td> <input type="checkbox" name="checkboxes" id="checkboxes-0" value="1"> </td> </tr> <tr> <td> Rush </td> <td> <input type="checkbox" name="checkboxes" id="checkboxes-0" value="1"> </td> <td> <input type="checkbox" name="checkboxes" id="checkboxes-0" value="1"> </td> </tr> <tr> <td> Notes: </td> <td> <input type="checkbox" name="checkboxes" id="checkboxes-0" value="1"> </td> <td> <input type="checkbox" name="checkboxes" id="checkboxes-0" value="1"> </td> </tr> </tbody> </table> </div> </div> </div>