<html>
<head>
<title>T2 - Appointment Request Form</title>
<style>
legend {
font-size: x-large;
}
td {
font-size: larger;
}
input {
font-size: medium;
}
</style>
</head>
<body align="center">
<h1>Task 2 - Appointment Request Form</h1>
<form>
<table cellpadding="10" align="center">
<tr>
<td>
<fieldset>
<legend>Patient Information</legend>
<table cellpadding="4">
<tr>
<td>First Name:</td>
<td><input type="text" name="firstname" placeholder="First Name" required></td>
</tr>
<tr>
<td>Last Name:</td>
<td><input type="text" name="lastname" placeholder="Last Name" required></td>
</tr>
<tr>
<td>Date of Birth:</td>
<td><input type="date" name="dob" required></td>
</tr>
<tr>
<td>Email:</td>
<td><input type="email" name="email" placeholder="Email" required></td>
</tr>
<tr>
<td>Phone Number:</td>
<td><input type="tel" name="phone" placeholder="Phone Number" required></td>
</tr>
<tr>
<td>Gender:</td>
<td>
<input type="radio" name="gender" value="male"> Male
<input type="radio" name="gender" value="female"> Female
</td>
</tr>
</table>
</fieldset>
</td>
</tr>
<tr>
<td>
<fieldset>
<legend>Appointment Details</legend>
<table cellpadding="4">
<tr>
<td>Preferred Doctor:</td>
<td>
<select name="doctor" required>
<option value="" disabled selected>Select Doctor</option>
<option value="dr_kd_srivastava">Dr. Kuldeep Srivastava</option>
<option value="dr_tarun_srivastava">Dr. Tarun Srivastava</option>
<option value="dr_dk_srivastava">Dr. DK Srivastava</option>
</select>
</td>
</tr>
<tr>
<td>Preferred Date:</td>
<td><input type="date" name="appointment_date" required></td>
</tr>
<tr>
<td>Preferred Time:</td>
<td><input type="time" name="appointment_time" required></td>
</tr>
<tr>
<td>Reason for Appointment:</td>
<td><textarea name="reason" rows="4" cols="50" maxlength="40"
placeholder="Reason for Appointment" required></textarea></td>
</tr>
</table>
</fieldset>
</td>
</tr>
<tr>
<td>
<fieldset>
<legend>Additional Information</legend>
<table cellpadding="4">
<tr>
<td>Insurance Provider:</td>
<td><input type="text" name="insurance" placeholder="Insurance Provider"></td>
</tr>
<tr>
<td>Known Allergies:</td>
<td><input type="text" name="allergies" placeholder="Known Allergies"></td>
</tr>
<tr>
<td>Current Medications:</td>
<td><input type="text" name="medications" placeholder="Current Medications"></td>
</tr>
<tr>
<td>Additional Notes:</td>
<td><textarea name="notes" rows="4" cols="50" placeholder="Additional Notes"
maxlength="50"></textarea></td>
</tr>
</table>
</fieldset>
</td>
</tr>
<tr>
<td align="center"><input type="submit" value="Submit Appointment Request"></td>
</tr>
</table>
</form>
</body>
</html>