<div class="bt_bb_cf7_form bt_bb_cf7_twocol_form">
<div class="bt_bb_cf7_row">
<div class="bt_bb_cf7_element"><p><span class="bt_bb_required">Su Nombre</span></p>[text* your-name]</div>
<div class="bt_bb_cf7_element"><p><span class="bt_bb_required">Su Email</span></p>[email* your-email] </div>
</div>
<div class="bt_bb_cf7_row">
<div class="bt_bb_cf7_element"><p>Servicio</p>[select Doctor first_as_label "Seleccione servicio aquí" "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 class="bt_bb_cf7_element"><p><span class="bt_bb_required">Fecha de interés</span></p>[date* date-638 placeholder "Seleccione fecha"]</div>
</div>
<div class="bt_bb_cf7_button bt_bb_cf7_button_larger bt_bb_align_to_center">[submit "Solicitar Cita"]</div>
</div>