{!! Form::text('first_name') -> label(trans('benefit_card::requestform.label.first_name')) -> placeholder(trans('benefit_card::requestform.placeholder.first_name'))!!}

{!! Form::text('last_name') -> label(trans('benefit_card::requestform.label.last_name')) -> placeholder(trans('benefit_card::requestform.placeholder.last_name'))!!}

{!! Form::text('mobile') -> label(trans('benefit_card::requestform.label.mobile')) -> placeholder(trans('benefit_card::requestform.placeholder.mobile'))!!}

{!! Form::text('email') -> label(trans('benefit_card::requestform.label.email')) -> placeholder(trans('benefit_card::requestform.placeholder.email'))!!}

{!! Form::text('area') -> label(trans('benefit_card::requestform.label.area')) -> placeholder(trans('benefit_card::requestform.placeholder.area'))!!}

{!! Form::text('street_address') -> label(trans('benefit_card::requestform.label.street_address')) -> placeholder(trans('benefit_card::requestform.placeholder.street_address'))!!}

{!! Form::text('area') -> label(trans('benefit_card::requestform.label.area')) -> placeholder(trans('benefit_card::requestform.placeholder.area'))!!}

{!! Form::text('building_number') -> label(trans('benefit_card::requestform.label.building_number')) -> placeholder(trans('benefit_card::requestform.placeholder.building_number'))!!}

{!! Form::text('appartment_number') -> label(trans('benefit_card::requestform.label.appartment_number')) -> placeholder(trans('benefit_card::requestform.placeholder.appartment_number'))!!}

{!! Form::inline_radios('pregnant') -> radios(trans('benefit_card::requestform.options.pregnant')) -> label(trans('benefit_card::requestform.label.pregnant'))!!}

{!! Form::text('size_diaper') -> label(trans('benefit_card::requestform.label.size_diaper')) -> placeholder(trans('benefit_card::requestform.placeholder.size_diaper'))!!}

{!! Form::text('children_age') -> label(trans('benefit_card::requestform.label.children_age')) -> placeholder(trans('benefit_card::requestform.placeholder.children_age'))!!}