<div class="dark-form style3 contact-slide row">
    <div class="col-md-12">[text* FullName placeholder "Full Name"]</div>    
    <div class="col-md-12">[select* menu-904 "Select Department" "Child Health" "Senior Care" "Newborn Baby" "Neurology"]</div>
    <div class="col-md-12">[select* menu-904 "Select Doctors" "Sara Jackson" "Jonathan Gomez" "Ruth Miller"]</div>
    <div class="col-md-12">[date* date-840 min:2022-01-14 max:2026-12-14]</div>
    <div class="col-md-12 btn-submit-right"><button type="submit">Make Appointment<i class="carenow-icon-long-arrow-right2"></i></button></div>
</div>