<div class="bt_bb_cf7_form">
    <div class="bt_bb_cf7_row">
        <div class="bt_bb_cf7_element">[text* your-name placeholder "Su Nombre *"]</div></div>
    <div class="bt_bb_cf7_row">
        <div class="bt_bb_cf7_element">[email* your-email placeholder "Su Email *"]</div></div>
    <div class="bt_bb_cf7_row">
    <div class="bt_bb_cf7_row">
        <div class="bt_bb_cf7_element">[tel tel placeholder "Teléfono"]</div></div>
    <div class="bt_bb_cf7_row">
        <div class="bt_bb_cf7_element">[select menu-974 "Seleccione aquí el servicio" "Implantología dental" "Cirugía regenerativa, estética y preprotésica" "Diseñó digital de sonrisa ( scanner- cad cam )" "Prótesis de alta estética , titanio y polieteretercetona" "Ortodoncia digital de tecnología en autoligado" "Tratamiento de conductos ( endodoncia)"]</div></div>
    <div class="bt_bb_cf7_row">
        <div class="bt_bb_cf7_element">[date* appointment-date placeholder "Fecha *"]</div></div>
    <div class="bt_bb_cf7_row">
        <div class="bt_bb_cf7_element">[textarea your-message x3 placeholder "Mensaje adicional sobre su visita"]</div></div>
    <div class="bt_bb_cf7_row">
        <div class="bt_bb_cf7_button bt_bb_cf7_button_larger bt_bb_cf7_element">[submit "Solicitar cita"]</div></div>
</div>