                    <input class="form-control " name="fecha" type="date" required="required"
                           data-validation-required-message="Ingrese un sintoma por favor">
                </div>
            </div>

            <div class="col-lg-8 col-md-8 col-sm-8 col-xs-12">
                <div class="form-group">
                    <label>Descripcion</label>
                    <textarea name="descripcion" cols="5" rows="5" class="form-control"></textarea>
                </div>
            </div>

            <hr width="1500" style="background: #99999961;">