<link href="//maxcdn.bootstrapcdn.com/bootstrap/3.3.0/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css"> <script src="//maxcdn.bootstrapcdn.com/bootstrap/3.3.0/js/bootstrap.min.js"></script> <script src="//code.jquery.com/jquery-1.11.1.min.js"></script> <!------ Include the above in your HEAD tag ----------> <div class="container"> <div class="row"> <div class="col-xs-12 col-sm-8 col-md-6 col-sm-offset-2 col-md-offset-3"> <form role="form" class="form-horizontal"> <h3>Registrasi pasien baru</h3> <div class="well well-lg"> <div class="form-group"> <label for="fullname">Nama Lengkap</label> <input type="text" class="form-control" id="fullname" placeholder="Nama Lengkap"> </div> <div class="form-group"> <label for="gender">Jenis Kelamin</label> <select id="gender" name="gender" class="form-control"> <option>Laki-laki</option> <option>Perempuan</option> </select> </div> <div class="form-group"> <label for="dateofbirth">Tanggal Lahir</label> <input type="text" class="form-control" id="dateofbirth" placeholder="dd/mm/yyyy"> </div> <div class="form-group"> <label for="address">Alamat </label> <textarea class="form-control" id="address" name="address"></textarea> </div> <div class="form-group"> <label for="religion">Agama</label> <input type="text" class="form-control" id="religion" placeholder="Agama"> </div> <div class="form-group"> <label for="paymentMethod">Metode Pembayaran</label> <select id="paymentMethod" name="paymentMethod" class="form-control"> <option>Askes</option> <option>BPJS</option> <option>Perusahaan</option> <option>Pribadi</option> </select> </div> </div> <center><input type="submit" value="Register" class="btn btn-block btn-primary"></center> </form> </div> </div> </div>