<div class="dark-form style3 row">
    <div class="col-md-12">[text* FullName placeholder "Full Name"]</div>
    <div class="col-md-12">[select* menu-14 "Choose Service" "Beauty Aesthetic" "Porcelain Crowns"]</div>
    <div class="col-md-12">[select* menu-14 "Select Doctor" "Sara Jackson" "Jonathan Gomez" "Ruth Miller"]</div>
    <div class="col-md-12"><button type="submit">Send Request Now<i class="carenow-icon-long-arrow-right2"></i></button></div>
</div>