[vc_row][vc_column][select* deptname "Select Department" "Gynacelogy" "Blood Bank" "Ophthalmology" "Oncology"][/vc_column][dt_sc_hr_top value="10" /][dt_sc_hr_top value="5" /][vc_column width="1/2"][text* firstname placeholder "First Name"][/vc_column][vc_column width="1/2"][text* lastname placeholder "Last Name"][/vc_column]
[dt_sc_hr_invisible size="xsmall" /]
[vc_column width="1/2"][email* emailaddress placeholder "Email Address"][/vc_column]
[vc_column width="1/2"][tel* phonumber placeholder "Phone Number"][/vc_column]
[dt_sc_hr_invisible size="xsmall" /]
[vc_column width="1/2"][date* date placeholder "Date mm/dd/yyyy"][/vc_column]
[vc_column width="1/2"][select* selection "Male" "Female"][/vc_column]
[dt_sc_hr_invisible size="xsmall" /][dt_sc_hr_custom type="clear" class="" /][vc_column][textarea depttextarea placeholder "Your Message"][dt_sc_hr_top value="5" /]<p>[submit "Book Now"]</p>[/vc_column][/vc_row]