Patient Feedback Form

<form
  action="https://flowqen.com/api/f/YOUR_FORM_ID"
  method="POST"
  class="max-w-xl mx-auto rounded-[32px] border border-white/10 bg-[#1f1a17] px-6 py-7 shadow-[0_28px_90px_rgba(23,16,12,0.28)] sm:px-8"
>
  <h2 class="text-2xl font-semibold tracking-tight text-white mb-6">Patient Feedback Form</h2>

  <div class="space-y-4">
    <div>
      <label class="mb-1.5 block text-sm font-medium text-stone-200">Visit Date</label>
      <input type="date" name="visitDate" class="w-full rounded-[20px] border border-white/10 bg-white/5 px-4 py-3 text-sm text-white outline-none transition placeholder:text-stone-400 focus:border-[#ff8a6c] focus:ring-4 focus:ring-[#E14E3A]/18" required />
    </div>

    <div>
      <label class="mb-1.5 block text-sm font-medium text-stone-200">Department</label>
      <select name="department" class="w-full rounded-[20px] border border-white/10 bg-white/5 px-4 py-3 text-sm text-white outline-none transition focus:border-[#ff8a6c] focus:ring-4 focus:ring-[#E14E3A]/18" required>
        <option value="">Select...</option>
        <option value="General Practice">General Practice</option>
        <option value="Pediatrics">Pediatrics</option>
        <option value="Cardiology">Cardiology</option>
        <option value="Emergency">Emergency</option>
        <option value="Other">Other</option>
      </select>
    </div>

    <div>
      <label class="mb-1.5 block text-sm font-medium text-stone-200">Overall Experience</label>
      <select name="overallRating" class="w-full rounded-[20px] border border-white/10 bg-white/5 px-4 py-3 text-sm text-white outline-none transition focus:border-[#ff8a6c] focus:ring-4 focus:ring-[#E14E3A]/18" required>
        <option value="">Select...</option>
        <option value="Excellent">Excellent</option>
        <option value="Good">Good</option>
        <option value="Average">Average</option>
        <option value="Poor">Poor</option>
      </select>
    </div>

    <div>
      <label class="mb-1.5 block text-sm font-medium text-stone-200">Comments</label>
      <textarea name="comments" rows="4" class="w-full rounded-[20px] border border-white/10 bg-white/5 px-4 py-3 text-sm text-white outline-none transition placeholder:text-stone-400 focus:border-[#ff8a6c] focus:ring-4 focus:ring-[#E14E3A]/18 resize-none" placeholder="Tell us about your experience..." required></textarea>
    </div>

    <div>
      <label class="mb-1.5 block text-sm font-medium text-stone-200">Would you recommend us?</label>
      <div class="mt-2 grid gap-2">
        <label class="inline-flex items-center gap-2 rounded-[20px] border border-white/10 bg-white/5 px-3 py-2 text-sm text-stone-100"><input type="radio" name="recommend" value="Yes" class="accent-[#E14E3A]" required /> Yes</label>
        <label class="inline-flex items-center gap-2 rounded-[20px] border border-white/10 bg-white/5 px-3 py-2 text-sm text-stone-100"><input type="radio" name="recommend" value="No" class="accent-[#E14E3A]" required /> No</label>
        <label class="inline-flex items-center gap-2 rounded-[20px] border border-white/10 bg-white/5 px-3 py-2 text-sm text-stone-100"><input type="radio" name="recommend" value="Maybe" class="accent-[#E14E3A]" required /> Maybe</label>
      </div>
    </div>
  </div>

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

  <button type="submit" class="mt-6 w-full rounded-[20px] bg-white py-3 text-sm font-semibold text-[#201814] transition hover:bg-stone-100">
    Submit
  </button>
</form>