"Appointment REQUEST"
Bootstrap 3.0.0 Snippet by cresignsys

<link href="//netdna.bootstrapcdn.com/bootstrap/3.0.0/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css"> <script src="//netdna.bootstrapcdn.com/bootstrap/3.0.0/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"> <fieldset> <!-- Form Name --> <legend>Appointment REQUEST</legend> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="FullName ">Full Name </label> <div class="col-md-4"> <input id="FullName " name="FullName " type="text" placeholder="" class="form-control input-md"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="ApartmentHospital">Apartment / Hospital</label> <div class="col-md-4"> <input id="ApartmentHospital" name="ApartmentHospital" type="text" placeholder="" class="form-control input-md"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="Email">E-mail</label> <div class="col-md-4"> <input id="Email" name="Email" type="text" placeholder="" class="form-control input-md"> </div> </div> <!-- Textarea --> <div class="form-group"> <label class="col-md-4 control-label" for="textarea">Please enter details of requested work and/or description of problem *</label> <div class="col-md-4"> <textarea class="form-control" id="textarea" name="textarea"></textarea> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="PhoneNumber">Phone Number *</label> <div class="col-md-4"> <input id="PhoneNumber" name="PhoneNumber" type="text" placeholder="" class="form-control input-md"> </div> </div> <!-- Button --> <div class="form-group"> <label class="col-md-4 control-label" for="singlebutton"></label> <div class="col-md-4"> <button id="singlebutton" name="singlebutton" class="btn btn-primary">Submit</button> </div> </div> </fieldset> </form>

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