<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>
<div class="banner3">
<div class="py-5 banner" style="background-image:url(https://www.wrappixel.com/demos/ui-kit/wrapkit/assets/images/form-banners/banner2/banner-bg.jpg);">
<div class="container">
<div class="row">
<div class="col-md-7 col-lg-5">
<h3 class="my-3 text-white font-weight-medium text-uppercase">Book Appointment</h3>
<div class="bg-white">
<div class="form-row border-bottom">
<div class="p-4 left border-right w-50">
<label class="text-inverse font-12 text-uppercase">First Name</label>
<input type="text" class="border-0 p-0 font-14 form-control" placeholder="Your First Name" />
</div>
<div class="p-4 right w-50">
<label class="text-inverse font-12 text-uppercase">Last Name</label>
<input type="text" class="border-0 p-0 font-14 form-control" placeholder="Your Last Name" />
</div>
</div>
<div class="form-row border-bottom p-4">
<label class="text-inverse font-12 text-uppercase">Email Address</label>
<input type="text" class="border-0 p-0 font-14 form-control" placeholder="Enter your Email Address" />
</div>
<div class="form-row border-bottom p-4">
<label class="text-inverse font-12 text-uppercase">Phone Number</label>
<input type="text" class="border-0 p-0 font-14 form-control" placeholder="Enter your Phone Number" />
</div>
<div class="form-row border-bottom p-4 position-relative">
<label class="text-inverse font-12 text-uppercase">Booking Date</label>
<div class="input-group date">
<input type="text" class="border-0 p-0 font-14 form-control" id="dp" placeholder="Select the Appointment Date" />
<label class="mt-2" for="dp"><i class="icon-calendar mt-1"></i></label>
</div>
</div>
