n class="hidden-xs" style="font-size: 14px;"> Periode Rawat</span>
          </span>
          <ul class="dropdown-menu dropdown-menu-right">
            <li style="padding-left:5px;padding-right:5px;">
              <input type="text" id="periode_rawat_jalan" class="form-control periode_rawat_jalan" name="periode_rawat_jalan" required>
            </li>
            <li style="padding-left:5px;padding-right:5px;margin-top:5px;">
              <input type="text" id="periode_rawat_jalan_akhir" class="form-con