<div class="form-horizontal-upload row">
        <div class="col-12 cf-file">
            [file file-up limit:6MB filetypes:JPEG|JPG|PNG|PDF|TXT ]<p class="cf-text">
              <span class="tit">Drag and drop or click here to upload prescription</span><span class="des">JPEG, JPG, PNG &amp; PDF supported. Maximum file size – 6MB</span> </p>
        </div>
        <div class="col-md-6 cf-name"><label for="name">Your name</label>
            [text* text-182 class:form-control akismet:author]
        </div>
        <div class="col-md-6 cf-phone"><label for="tel">Phone</label>
            [tel* tel-502 class:form-control akismet:author]
        </div>
        <div class="col-12 cf-email"><label for="email">Email</label>
           [email* email-216 class:form-control akismet:author]
        </div>
        <div class="col-12 cf-address"><label for="name">City</label>
            [select select-add "Select City" "New York" "Chicago" "Los Angeles"]
        </div>
        <div class="col-12 cf-textarea"><label for="message">Message</label>
            [textarea textarea-552 class:form-control placeholder "Note about your prescription"]
        </div>
        <div class="col-12 col-md-offset-10 cf-submit">
            [submit class:btn class:btn-default "Submit Prescription"]
        </div>
</div>