<p>[select* menu-919 "Department" "Pathology" "X-Ray" "Gynecology"] </p>
<p>[text* fullname placeholder "Full Name"]</p>
<p>[email* email placeholder "Email"]</p>
<p>[date* appointmentdate placeholder "Appointment Date"]</p>
<p>[textarea message x4 placeholder "Message"] </p>
<p>[submit "Submit"]</p>