<div class="bt_bb_cf7_form">
<div class="bt_bb_cf7_row">
<div class="bt_bb_cf7_element">[email* customer-email placeholder "Your email address *"]</div></div>
<div class="bt_bb_cf7_row">
<div class="bt_bb_cf7_element">[select Doctor first_as_label "Select Your Dentist" "Allen Fischer" "Alex Terrel" "Michél Anderson" "Edwin Southgate" "Carlie Addison"]</div></div>
<div class="bt_bb_cf7_row">
<div class="bt_bb_cf7_element">[date* date-638 placeholder "Appointment date *"]</div></div>
<div class="bt_bb_cf7_button bt_bb_cf7_button_larger bt_bb_accent_submit bt_bb_closer_button bt_bb_full_width">[submit "Book your Dentist"]</div>
</div>