<div class="row"><div class="col-md-6"> [text* your-name placeholder:"Full Name"]</div><div class="col-md-6"> [email* your-email placeholder:"Email Address"]</div><div class="col-md-6"> [text your-phone placeholder:"Phone Number"]</div><div class="col-md-6"> [select menu-154 class:selectpicker "Discussion For" "Basic Query" "Patient Admission"]</div><div class="col-md-12"> [textarea your-message placeholder:"Message"]</div><div class="col-md-12 text-center"> [submit class:thm-btn class:contact-one__btn "Submit Now"]</div></div>