<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-3"> <label for="inputStatus" class="control-label">Nombres:</label> <input class="form-control" name="num_pedido" type="text" placeholder="Apellidos:" /> </div> <div class="col-md-3"> <label for="inputStatus" class="control-label">Apeliidos</label> <input class="form-control" name="num_pedido" type="text" placeholder="Nombres:" /> </div> <div class="col-md-3"> <label for="inputStatus" class="control-label">Fecha de Nacimiento</label> <input class="form-control" name="num_pedido" type="date" placeholder="Fecha de Nacimiento:" /> </div> <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> </div> <div class="col-md-12"> <div class="form-group"> <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-5"> <label for="inputStatus" class="control-label">E-mail:</label> <input class="form-control" name="num_pedido" type="text" placeholder="E-mai:" /> </div> <div class="col-md-2"> <label for="inputStatus" class="control-label">Tiempo de Quirófano:</label> <select class="form-control"> <option value="">Seleccione..</option> <option value="1 Hora">1 Hora</option> <option value="2 Horas">2 Horas</option> <option value="3 Horas">3 Horas</option> <option value="4 Horas">4 Horas</option> <option value="5 Horas">5 Horas</option> <option value="6 Horas">6 Horas</option> <option value="7 Horas">7 Horas</option> <option value="8 Horas">8 Horas</option> <option value="9 Horas">9 Horas</option> <option value="10 Horas">10 Horas</option> <option value="11 Horas">11 Horas</option> <option value="12 Horas">12 Horas</option> <option value="13 Horas">13 Horas</option> <option value="14 Horas">14 Horas</option> <option value="15 Horas">15 Horas</option> <option value="16 Horas">16 Horas</option> <option value="17 Horas">17 Horas</option> <option value="18 Horas">18 Horas</option> <option value="19 Horas">19 Horas</option> <option value="20 Horas">20 Horas</option> <option value="21 Horas">21 Horas</option> <option value="22 Horas">22 Horas</option> <option value="23 Horas">23 Horas</option> <option value="24 Horas">24 Horas</option> </select> </div> <div class="col-md-2"> <label for="inputStatus" class="control-label">Tiempo de Hospitalización:</label> <select class="form-control"> <option value="">Seleccione..</option> <option value="1 Día">1 Día</option> <option value="2 Dias">2 Dias</option> <option value="3 Dias">3 Dias</option> <option value="4 Dias">4 Dias</option> <option value="5 Dias">5 Dias</option> <option value="6 Dias">6 Dias</option> <option value="7 Dias">7 Dias</option> <option value="8 Dias">8 Dias</option> <option value="9 Dias">9 Dias</option> <option value="10 Dias">10 Dias</option> <option value="11 Dias">11 Dias</option> <option value="12 Dias">12 Dias</option> <option value="13 Dias">13 Dias</option> <option value="14 Dias">14 Dias</option> <option value="15 Dias">15 Dias</option> <option value="16 Dias">16 Dias</option> <option value="17 Dias">17 Dias</option> <option value="18 Dias">18 Dias</option> <option value="19 Dias">19 Dias</option> <option value="20 Dias">20 Dias</option> <option value="21 Dias">21 Dias</option> <option value="22 Dias">22 Dias</option> <option value="23 Dias">23 Dias</option> <option value="24 Dias">24 Dias</option> <option value="25 Dias">25 Dias</option> <option value="26 Dias">26 Dias</option> <option value="27 Dias">27 Dias</option> <option value="28 Dias">28 Dias</option> <option value="29 Dias">29 Dias</option> <option value="30 Dias">30 Dias</option> <option value="31 Dias">31 Dias</option> <option value="32 Dias">32 Dias</option> <option value="33 Dias">33 Dias</option> <option value="34 Dias">34 Dias</option> <option value="35 Dias">35 Dias</option> <option value="36 Dias">36 Dias</option> <option value="37 Dias">37 Dias</option> <option value="38 Dias">38 Dias</option> <option value="39 Dias">39 Dias</option> <option value="40 Dias">40 Dias</option> <option value="41 Dias">41 Dias</option> <option value="42 Dias">42 Dias</option> <option value="43 Dias">43 Dias</option> <option value="44 Dias">44 Dias</option> <option value="45 Dias">45 Dias</option> <option value="46 Dias">46 Dias</option> <option value="47 Dias">47 Dias</option> <option value="48 Dias">48 Dias</option> <option value="49 Dias">49 Dias</option> <option value="50 Dias">50 Dias</option> <option value="51 Dias">51 Dias</option> <option value="52 Dias">52 Dias</option> <option value="53 Dias">53 Dias</option> <option value="54 Dias">54 Dias</option> <option value="55 Dias">55 Dias</option> <option value="56 Dias">56 Dias</option> <option value="57 Dias">57 Dias</option> <option value="58 Dias">58 Dias</option> <option value="59 Dias">59 Dias</option> <option value="60 Dias">60 Dias</option> </select> </div> </div> </div> <div class="col-md-12"> <div class="form-group"> <div class="col-md-3"> <label for="inputStatus" class="control-label">Diagnóstico:</label> <input class="form-control" name="num_pedido" type="text" placeholder="Diagnóstico:" /> </div> <div class="col-md-3"> <label for="inputStatus" class="control-label">Nombre y Apellido del Médico Tratante:</label> <input class="form-control" name="num_pedido" type="text" placeholder="Nombre y Apellido del Médico Tratant:" /> </div> <div class="col-md-3"> <label for="inputStatus" class="control-label">Nombre del Procedimiento::</label> <input class="form-control" name="num_pedido" type="text" placeholder=">Nombre del Procedimient:" /> </div> <div class="col-md-3"> <label for="inputStatus" class="control-label">Código para Procedimiento:</label> <input class="form-control" name="num_pedido" type="text" placeholder="Código para Procedimiento" /> </div> </div> </div> <div class="col-md-12"> <div class="form-group"> <div class="col-md-4"> <label for="inputStatus" class="control-label">Equipo Especial:</label> <textarea class="form-control" rows="2" id="comment"></textarea> </div> <div class="col-md-4"> <label for="inputStatus" class="control-label">Suministros Especiales:</label> <textarea class="form-control" rows="2" id="comment"></textarea> </div> <div class="col-md-4"> <label for="inputStatus" class="control-label">Otros requerimientos especiales:</label> <textarea class="form-control" rows="2" id="comment"></textarea> </div> </div> </div> <div class="col-md-12"> <button type="button" class="btn btn-primary btn-block"><b>Registrar</b></button> </div> </form>