<div class="row">
	<div class="col-md-6">
		<label>Full Name</label>
		[text* your-name placeholder "e.g., Jonh Doe"]
	</div>
	<div class="col-md-6">
		<label>Your Phone</label>
		[tel* yout-phone]
	</div>
	<div class="col-md-6">
		<label>Date of Birth</label>
		[date* DOB]
	</div>
	<div class="col-md-6">
		<label>Gender</label>
		[select* Gender "Male" "Female"]
	</div>
<div class="col-md-6">
		<label>Email Address</label>
		[email* Email]
	</div>
	<div class="col-md-6">
		<label>Physical Address</label>
		[text* Address]
	</div>
<div class="col-md-6">
		<label>Medical Aid Provider</label>
		[text* MedicalAid]
	</div>
	<div class="col-md-6">
		<label>Medical Aid Number</label>
		[text* MANumber]
	</div>
	<div class="col-md-12" style="margin-top: 10px;">
		[submit "Sign Up"]
	</div>
</div>