<div class="default-form contactus-form"><div class="row"><div class="col-lg-12 col-md-12 col-sm-12 col-xs-12"><div class="form-row"> [text Fullname placeholder "Full name"] <span class="ti-user"> </span></div></div><div class="col-lg-12 col-md-12 col-sm-12 col-xs-12"><div class="form-row"> [email Emailaddress placeholder "Email address"]<span class="ti-email"></span></div></div><div class="col-lg-12 col-md-12 col-sm-12 col-xs-12"><div class="form-row"> [select NeedAppointment class:right-bar "General Inquiry" "Need Appointment"]<span class="ti-angle-down"></span></div></div><div class="col-lg-12 col-md-12 col-sm-12 col-xs-12"><div class="form-row"> [textarea Message placeholder "Message"] </div></div><div class="col-lg-12 col-md-12 col-sm-12 col-xs-12"><div class="form-row"> [submit class:btn "Send &amp; book your consultation"]</div></div></div></div>