<!DOCTYPE html>
<html lang=”en”>
<head>
<meta charset=”UTF-8″>
<meta name=”viewport” content=”width=device-width, initial-scale=1.0″>
<title>Đăng ký khám chữa bệnh</title>
<link rel=”stylesheet” href=”https://stackpath.bootstrapcdn.com/bootstrap/4.5.2/css/bootstrap.min.css”>
</head>
<body>
<div class=”container”>
<h2 class=”mt-5″>Đăng ký khám chữa bệnh</h2>
<form action=”/” method=”post”>
<div class=”form-group”>
<label for=”fullname”>Họ và tên:</label>
<input type=”text” class=”form-control” id=”fullname” name=”fullname” required>
</div>
<div class=”form-group”>
<label for=”dob”>Ngày sinh:</label>
<input type=”date” class=”form-control” id=”dob” name=”dob” required>
</div>
<div class=”form-group”>
<label for=”gender”>Giới tính:</label>
<select class=”form-control” id=”gender” name=”gender” required>
<option value=”male”>Nam</option>
<option value=”female”>Nữ</option>
<option value=”other”>Khác</option>
</select>
</div>
<div class=”form-group”>
<label for=”phone”>Số điện thoại:</label>
<input type=”tel” class=”form-control” id=”phone” name=”phone” required>
</div>
<div class=”form-group”>
<label for=”email”>Email:</label>
<input type=”email” class=”form-control” id=”email” name=”email”>
</div>
<div class=”form-group”>
<label for=”address”>Địa chỉ:</label>
<input type=”text” class=”form-control” id=”address” name=”address”>
</div>
<div class=”form-group”>
<label for=”symptoms”>Triệu chứng:</label>
<textarea class=”form-control” id=”symptoms” name=”symptoms” rows=”4″></textarea>
</div>
<button type=”submit” class=”btn btn-primary”>Đăng ký</button>
</form>
</div>
</body>
</html>
