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<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<title>Submit Data</title>
</head>
<body>
<h1>Submit Your Data</h1>
<form action="/pacjent/" method="post">
<label for="pesel">Pesel:</label><br>
<input type="text" id="pesel" name="pesel" required><br><br>
<label for="name">Imie:</label><br>
<input type="text" id="name" name="name" required><br><br>
<label for="surname">Nazwisko:</label><br>
<input type="text" id="surname" name="surname" required><br><br>
<p>Płeć:</p>
<input type="radio" id="male" name="gender" value="male">
<label for="male">Mężczyzna</label>
<input type="radio" id="female" name="gender" value="female">
<label for="female">Kobieta</label><br><br>
<label for="phone">Numer telefonu:</label><br>
<input type="number" id="phone" name="phone" required><br><br>
<label for="birthdate">Data urodzenia:</label><br>
<input type="date" id="birthdate" name="birthdate" required><br><br>
<label for="address">Adres:</label><br>
<input type="text" id="address" name="address" required><br><br>
<label for="sickness">Choroba:</label><br>
<input type="text" id="sickness" name="sickness" required><br><br>
<button type="submit">Submit</button>
</form>
</body>
</html>
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