"Facebook style signup form"
Bootstrap 3.0.0 Snippet by sergikm

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<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 ---------->
<div class="container" id="wrap">
<div class="row">
<div class="col-md-6 col-md-offset-3">
<form action="r" method="post" accept-charset="utf-8" class="form" role="form">
<legend>Patient/Client Information</legend>
<input type="text" name="firstname" value="" class="form-control input-lg" placeholder="First Name" />
<div class="row">
<div class="col-xs-4 ">
<input type="text" class="form-control input-lg" placeholder="Middle Name">
</div>
</div>
<input type="text" name="midlename" value="" class="form-control input-lg" placeholder="Middle Name" />
<input type="text" name="lastname" value="" class="form-control input-lg" placeholder="Last Name" />
<input type="text" name="lastname" value="" class="form-control input-lg" placeholder="Date Of Birth (mm/dd/yyyy)"/>
<input type="text" name="lastname" value="" class="form-control input-lg" placeholder="Street"/>
<input type="text" name="lastname" value="" class="form-control input-lg" placeholder="City"/>
<input type="text" name="email" value="" class="form-control input-lg" placeholder="Your Email" />
<input type="password" name="password" value="" class="form-control input-lg" placeholder="Password" /><input type="password" name="confirm_password" value="" class="form-control input-lg" placeholder="Confirm Password" /> <label>Birth Date</label> <div class="row">
<div class="col-xs-4 col-md-4">
<select name="month" class = "form-control input-lg">
<option value="01">Jan</option>
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#wrap{
background-image: -ms-linear-gradient(top, #FFFFFF 0%, #D3D8E8 100%);
/* Mozilla Firefox */
background-image: -moz-linear-gradient(top, #FFFFFF 0%, #D3D8E8 100%);
/* Opera */
background-image: -o-linear-gradient(top, #FFFFFF 0%, #D3D8E8 100%);
/* Webkit (Safari/Chrome 10) */
background-image: -webkit-gradient(linear, left top, left bottom, color-stop(0, #FFFFFF), color-stop(1, #D3D8E8));
/* Webkit (Chrome 11+) */
background-image: -webkit-linear-gradient(top, #FFFFFF 0%, #D3D8E8 100%);
/* W3C Markup, IE10 Release Preview */
background-image: linear-gradient(to bottom, #FFFFFF 0%, #D3D8E8 100%);
background-repeat: no-repeat;
background-attachment: fixed;
}
legend{
color:#141823;
font-size:25px;
font-weight:bold;
}
.signup-btn {
background: #79bc64;
background-image: -webkit-linear-gradient(top, #79bc64, #578843);
background-image: -moz-linear-gradient(top, #79bc64, #578843);
background-image: -ms-linear-gradient(top, #79bc64, #578843);
background-image: -o-linear-gradient(top, #79bc64, #578843);
background-image: linear-gradient(to bottom, #79bc64, #578843);
-webkit-border-radius: 4;
-moz-border-radius: 4;
border-radius: 4px;
text-shadow: 0px 1px 0px #898a88;
-webkit-box-shadow: 0px 0px 0px #a4e388;
-moz-box-shadow: 0px 0px 0px #a4e388;
box-shadow: 0px 0px 0px #a4e388;
font-family: Arial;
color: #ffffff;
font-size: 20px;
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