<br>

      <fieldset>
        <legend>Your Visit</legend>

        <label>Choose your Doctor</label><br>
        <select id="doctor">
          <option value="">-- Select a doctor --</option>
          <option value="dr-ray">Dr. Ray — General</option>
          <option value="dr-lee">Dr. Lee — Teeth</option>
          <option value="dr-sam">Dr. Sam — Eyes</option>
        </select><br><br>

        <label>Why are you visiting?</label><br>
        <input type="radio" name="reason" value="fever"> Fever<br>
        <input type="radio" name="reason" value="cold"> Cold<br>
        <input type="radio" name="reason" value="checkup"> Checkup<br>
        <input type="radio" name="reason" value="tooth"> Tooth Pain<br><br>

        <label>Any notes for the doctor?</label><br>
        <textarea id="notes" rows="3" cols="35" placeholder="e.g. I have had a sore throat for 2 days."></textarea><br>

      </fieldset>

      <br>

      <fieldset>
        <legend>Preferred Visit Day</legend>

        <input type="checkbox" value="mon"> Monday<br>
        <input type="checkbox" value="wed"> Wednesday<br>
        <input type="checkbox" value="fri"> Friday<br>

      </fieldset>

      <br>
      <input type="submit" value="Book My Appointment">