[text* full-name placeholder "Your Name"][text* email-address placeholder "Your Email"][text* phone-number class:wpcf7-phone-number placeholder "Your Phone"]

[select best-day "---Select Best Day---" "Monday" "Tuesday" "Wednesday" "Thursday" "Friday" "Saturday"][select best-time "---Select Best Time---" "Morning (8-12)" "Afternoon (12-3)" "Late Afternoon (3-5)" "Early Evening (5-7)"][text best-date class:wpcf7-date placeholder "Best Date"]

Best Date:[text best-date class:wpcf7-date]

First Time?:[select first-time "---First Time Appointment ---" "Yes" "No"]

Requested Service:[select requested-service "---Requested Service---" "New Patient Consultation" "Dental Emergency" "Cosmetic Dental Consult" "Teeth Cleaning" "Dental Checkup" "Other Dental Service"]

Other:[text other-service placeholder "If Other"]

Confirm By:[radio confirm-by use_label_element "Phone" "Text" "Email" "All" ]

[textarea comments placeholder "Comments"]

[submit "Submit Appointment Request"]