Patient Intake Form

<form
  action="https://flowqen.com/api/f/YOUR_FORM_ID"
  method="POST"
  class="max-w-lg mx-auto bg-white rounded-2xl shadow-sm border border-gray-200 p-8"
>
  <h2 class="text-xl font-bold text-gray-900 mb-6">Patient Intake Form</h2>

  <div class="space-y-4">
    <div>
      <label class="block text-sm font-medium text-gray-700 mb-1">Full Name</label>
      <input type="text" name="fullName" class="w-full border border-gray-300 rounded-lg px-4 py-2.5 text-sm focus:outline-none focus:ring-2 focus:ring-[#E14E3A]/20 focus:border-[#E14E3A]" placeholder="John Doe" required />
    </div>

    <div>
      <label class="block text-sm font-medium text-gray-700 mb-1">Date of Birth</label>
      <input type="date" name="dateOfBirth" class="w-full border border-gray-300 rounded-lg px-4 py-2.5 text-sm focus:outline-none focus:ring-2 focus:ring-[#E14E3A]/20 focus:border-[#E14E3A]" required />
    </div>

    <div>
      <label class="block text-sm font-medium text-gray-700 mb-1">Email</label>
      <input type="email" name="email" class="w-full border border-gray-300 rounded-lg px-4 py-2.5 text-sm focus:outline-none focus:ring-2 focus:ring-[#E14E3A]/20 focus:border-[#E14E3A]" placeholder="patient@email.com" required />
    </div>

    <div>
      <label class="block text-sm font-medium text-gray-700 mb-1">Phone</label>
      <input type="tel" name="phone" class="w-full border border-gray-300 rounded-lg px-4 py-2.5 text-sm focus:outline-none focus:ring-2 focus:ring-[#E14E3A]/20 focus:border-[#E14E3A]" placeholder="(555) 123-4567" required />
    </div>

    <div>
      <label class="block text-sm font-medium text-gray-700 mb-1">Insurance Provider</label>
      <input type="text" name="insuranceProvider" class="w-full border border-gray-300 rounded-lg px-4 py-2.5 text-sm focus:outline-none focus:ring-2 focus:ring-[#E14E3A]/20 focus:border-[#E14E3A]" placeholder="Aetna, Blue Cross, etc." required />
    </div>

    <div>
      <label class="block text-sm font-medium text-gray-700 mb-1">Current Medications</label>
      <textarea name="currentMedications" rows="4" class="w-full border border-gray-300 rounded-lg px-4 py-2.5 text-sm focus:outline-none focus:ring-2 focus:ring-[#E14E3A]/20 focus:border-[#E14E3A] resize-none" placeholder="List all current medications..." required></textarea>
    </div>

    <div>
      <label class="block text-sm font-medium text-gray-700 mb-1">Allergies</label>
      <textarea name="allergies" rows="4" class="w-full border border-gray-300 rounded-lg px-4 py-2.5 text-sm focus:outline-none focus:ring-2 focus:ring-[#E14E3A]/20 focus:border-[#E14E3A] resize-none" placeholder="List any known allergies..." required></textarea>
    </div>

    <div>
      <label class="block text-sm font-medium text-gray-700 mb-1">Emergency Contact</label>
      <input type="text" name="emergencyContact" class="w-full border border-gray-300 rounded-lg px-4 py-2.5 text-sm focus:outline-none focus:ring-2 focus:ring-[#E14E3A]/20 focus:border-[#E14E3A]" placeholder="Jane Doe — (555) 987-6543" required />
    </div>
  </div>

  <!-- Honeypot (spam protection) -->
  <div style="display:none">
    <input type="text" name="_gotcha" style="display:none" />
  </div>

  <button type="submit" class="w-full bg-[#E14E3A] text-white py-3 rounded-lg font-semibold hover:bg-[#c9432f] transition mt-6">
    Submit
  </button>
</form>