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<form action="#" class="p-5 bg-white">
  <div class="row form-group">
    <div class="col-md-6 mb-3 mb-md-0">
      <label class="font-weight-bold text-pink-s" for="fname">First Name</label>
      <input type="text" id="fname" class="form-control" placeholder="First Name">
    </div>
    <div class="col-md-6">
      <label class="font-weight-bold text-pink-s" for="lname">Last Name</label>
      <input type="text" id="lname" class="form-control" placeholder="Last Name">
    </div>
  </div>
  <div class="row form-group">
    <div class="col-md-6 mb-3 mb-md-0">
      <label class="font-weight-bold text-pink-s" for="date">Date</label>
      <input type="text" id="date" class="form-control datepicker px-2" placeholder="Date of visit">
    </div>
    <div class="col-md-6">
      <label class="font-weight-bold text-pink-s" for="email">Email</label>
      <input type="email" id="email" class="form-control" placeholder="Email">
    </div>
  </div>
  <div class="row form-group">
    <div class="col-md-12">
      <label class="font-weight-bold text-pink-s" for="treatment">Treatment Needed</label>
      <select name="treatment" id="treatment" class="form-control">
        <option value="">Dental exam and teeth cleaning</option>
        <option value="">Dental emergency</option>
        <option value="">Dental implants</option>
      </select>
    </div>
  </div>
  <div class="row form-group">
    <div class="col-md-12">
      <label class="font-weight-bold text-pink-s" for="note">Notes</label>
      <textarea name="note" id="note" cols="30" rows="5" class="form-control" placeholder="Write your notes or questions here..."></textarea>
    </div>
  </div>
  <div class="row form-group">
    <div class="col-md-12">
      <input type="submit" value="Send" class="btn btn-primary bg-pink-s" disabled="">
      <p>Coming Soon!</p>
    </div>
  </div>
</form>

Text Content

   
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Tirana Kamëz +355 69 587 0282 contact@smile-boutique.eu
   
 * Home
   
 * About
   * Gallery
   * FAQ
   
 * Services
   
 * Team
   
 * Testimonials
   
 * Contact

Our Priority


YOUR NEW SMILE


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First Name
Last Name
Date
Email
Treatment Needed Dental exam and teeth cleaning Dental emergency Dental implants
Notes

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