Professional Documents
Culture Documents
Pages 2
Pages 2
<h2>Patient Information</h2>
<table>
<tr>
<th>Patient Name:</th>
<td><input type="text" name="patient_name"></td>
</tr>
<tr>
<th>Date of Birth:</th>
<td><input type="date" name="date_of_birth"></td>
</tr>
<tr>
<th>Medical History:</th>
<td><textarea name="medical_history"></textarea></td>
</tr>
</table>
</body>
</html>