<div class="form-html__footer">
  <div class="row">
    <div class="col-md-12">
      <p class="color-theme font-bold">For clinic use only (optional)</p>
    </div>
  </div>
  <div class="row">
    <div class="col-md-2">
      <p class="color-theme font-bold">Hfea centre reference</p>
    </div>
    <div class="col-md-5">
      <p class="color-theme font-bold">Patient number (assigned by clinic)</p>
    </div>
    <div class="col-md-5">
      <p class="color-theme font-bold">Other relevant forms</p>
    </div>
  </div>
  <div class="row">
    <div class="col-md-2">
      <div class="input-container">
        <!-- TODO: SeparatedCharsString -->
        <input type='text'
          name='hfea1'
          class='letter'
          placeholder="H"
          maxlength='1'>
        <input type='text'
          name='hfea2'
          class='letter'
          placeholder="H"
          maxlength='1'>
        <input type='text'
          name='hfea3'
          class='letter'
          placeholder="H"
          maxlength='1'>
        <input type='text'
          name='hfea4'
          class='letter'
          placeholder="H"
          maxlength='1'>
        <input type='text'
          name='hfea5'
          class='letter'
          placeholder="H"
          maxlength='1'>
      </div>
    </div>
    <div class="col-md-5">
      <input />
    </div>
    <div class="col-md-5">
      <input />
    </div>
  </div>
  <div class="row pt-10">
    <div class="col-md-12 text-right">
      <p class="color-theme">Version 8, 3 April 2017</p>
    </div>
  </div>
</div>