<label> Your Country
[select* country "Jordan" "Palestine" "Saudi Arabia" "Egypt" "Algeria" "Sudan" "Iraq" "Morocco" "Yemen" "Syria" "Tunisia" "Somalia" "United Arab Emirates" "Libya" "Lebanon" "Oman" "Kuwait" "Mauritania" "Qatar" "Bahrain" "Djibouti" "Other Country"]
</label>

<label> Email
    [email* your-email] 
</label>

<label> Name
    [text your-name]
</label>

[radio sex use_label_element default:1 "Male" "Female"]

<label> Mobile
[tel* phone]
</label>

<label> Medical Complain
    [textarea your-message]
</label>

<label> Image
[file picturefile filetypes:pdf|jpg|jpeg|png]
</label>

[submit "Submit"]