<p>[select* menu-919 "Department" "Pathology" "X-Ray" "Gynecology"] </p>
<p>[text* fullname placeholder "Full Name"]</p>
<p>[date* birthdate placeholder "Date of Birth"]</p>
<p>[select* sex "Sex" "Female" "Male" "Child" ] </p>
<p>[text* telephone placeholder "Phone Number"]</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>