[text* nam placeholder "Your Name"]

[tel* tel placeholder "Contact Number"]

[date* date placeholder "Enter Date"]

[text* time placeholder "Enter Time in AM / PM"]

[one_third]Mode of Video Call[/one_third] [one_half_last]  [/one_half_last]
[checkbox* checkbox-26 "Whatsapp" "Google Duo" "Skype" "Facebook" "JusTalk" "LINE" "Viber" "WeChat" "Yahoo"]

.

[textarea textarea-6 placeholder "Additional Information"]

[submit "Send your request"]