"patient1"
Bootstrap 4.1.1 Snippet by gpad1234

<link href="//maxcdn.bootstrapcdn.com/bootstrap/4.1.1/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css"> <script src="//maxcdn.bootstrapcdn.com/bootstrap/4.1.1/js/bootstrap.min.js"></script> <script src="//cdnjs.cloudflare.com/ajax/libs/jquery/3.2.1/jquery.min.js"></script> <!------ Include the above in your HEAD tag ----------> <form class="form-horizontal"> <fieldset> <!-- Form Name --> <legend>Personal Details</legend> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="textinput">name:</label> <div class="col-md-4"> <input id="textinput" name="textinput" type="text" placeholder="" class="form-control input-md" required=""> <span class="help-block">First Name, Last Name, MI</span> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="textinput">address:</label> <div class="col-md-4"> <input id="textinput" name="textinput" type="text" placeholder="" class="form-control input-md" required=""> <span class="help-block">Street Address Line 1</span> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="textinput"></label> <div class="col-md-4"> <input id="textinput" name="textinput" type="text" placeholder="" class="form-control input-md"> <span class="help-block">Street Address Line 2</span> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="textinput"></label> <div class="col-md-4"> <input id="textinput" name="textinput" type="text" placeholder="" class="form-control input-md" required=""> <span class="help-block">City</span> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="textinput"></label> <div class="col-md-4"> <input id="textinput" name="textinput" type="text" placeholder="" class="form-control input-md" required=""> <span class="help-block">Zip Code</span> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="phone">phone:</label> <div class="col-md-4"> <input id="phone" name="phone" type="text" placeholder="(999)-(999-9999)" class="form-control input-md" required=""> <span class="help-block">Phone Number</span> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="email">email:</label> <div class="col-md-4"> <input id="email" name="email" type="text" placeholder="name@example.com" class="form-control input-md" required=""> <span class="help-block">example@example.com</span> </div> </div> </fieldset> </form>

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