Here is the code Im using for my referral form :
<div class=”row”>
<div class=”col-md-4″>[checkbox checkbox-315 “DOWNTOWN” ]<p>
215 East Quincy Street
Suite B100
San Antonio, Texas 78215
</p></div>
<div class=”col-md-4″>[checkbox checkbox-127 “LIVE OAK” ]<p>
12705 Toepperwein Road
San Antonio, Texas 78233
</p></div>
<div class=”col-md-4″>[checkbox checkbox-240 “MEDICAL CENTER”]
<p>
9102 Floyd Curl Drive
San Antonio, Texas 78240
</p></div>
</div>
<div class=”row”>
<div class=”col-md-4″><p>MEDICAL ONCOLOGY
<p>Phone: 210.490.2707</p>
<p>Direct Fax: 210-224-2720</p>
<p>[checkbox checkbox-467 “Jayasree Rao, MD”]</p>
<p>[checkbox checkbox-558 “Slavisa Gasic, MD”]</p>
</p>
<p>RADIATION ONCOLOGY
<p>Phone: 210.787.1822</p>
<p>Direct Fax: 210.299.8099</p>
[checkbox checkbox-454 “Frank Dancuart, MD”]
</p>
</div>
<div class=”col-md-4″><p>MEDICAL ONCOLOGY
<p>Phone: 210.616.9922</p>
<p>Direct Fax:210.979.0814</p>
<p>[checkbox checkbox-223 “Zulfi Jaffar, MD”]</p>
<p>[checkbox checkbox-223 “Navneet Mittal, MD”]</p>
</p>
<p>RADIATION ONCOLOGY
<p>Phone: 210.787.1822</p>
<p>Direct Fax: 210.299.8099</p>
[checkbox checkbox-454 “Frank Dancuart, MD”]
</p></div>
<div class=”col-md-4″><p>MEDICAL ONCOLOGY
<p>Phone: 210.616.9922</p>
<p>Direct Fax: 210.979.0814</p>
<p>[checkbox checkbox-788 “Zulfi Jaffar, MD”]</p>
<p>[checkbox checkbox-788 “Helen Goldberg, MD”]</p>
</p></div>
</div>
<hr>
<div class=”row”>
<div class=”col-md-4″>[checkbox checkbox-899 “STONE OAK”]<p>
19288 Stone Oak Parkway
Suite B
San Antonio, Texas 78258
</p></div>
<div class=”col-md-4″>[checkbox checkbox-141 “SOUTH”]<p>
12705 Toepperwein Road
San Antonio, Texas 78233
</p></div>
</div>
<div class=”row”>
<div class=”col-md-4″><p>MEDICAL ONCOLOGY
<p>Phone: 210.490.2707</p>
<p>Direct Fax: 210.490.2986</p>
<p>[checkbox checkbox-467 “Jayasree Rao, MD”]</p>
<p>[checkbox checkbox-558 “Slavisa Gasic, MD”]</p>
</p>
</div>
<div class=”col-md-4″><p>MEDICAL ONCOLOGY
<p>Phone: 210.787.1822</p>
<p>Direct Fax: 210.299.8099</p>
[checkbox checkbox-223 “Syed Raza, MD”]
</p>
</div>
</div>