<form id="consultation" method="POST" action="https://wikimom.vn/wp-json/consultation/customer" class="hlw-flex hlw-flex-col hlw-gap-3" novalidate="novalidate">
        <div class="hlw-text-center hlw-font-bold hlw-text-2xl hlw-text-[#005eac]">Đăng ký tư vấn Nhi khoa Online Miễn
            Phí
        </div>
        <div class="hlw-flex hlw-flex-col hlw-gap-1">
            <input type="text" name="mom_name" class="hlw-px-3 hlw-h-10 hlw-block hlw-border hlw-rounded hlw-outline hlw-outline-0" placeholder="Họ tên mẹ (*)" tabindex="0">
        </div>
        <div class="hlw-flex hlw-flex-col hlw-gap-1">
            <input type="text" name="phone" class="hlw-px-3 hlw-h-10 hlw-block hlw-border hlw-rounded hlw-outline hlw-outline-0" placeholder="Số điện thoại (*)" tabindex="0">
        </div>
        <div class="hlw-grid hlw-grid-cols-2 hlw-gap-6">
            <div class="hlw-flex hlw-flex-col hlw-gap-1">
                <input type="text" name="mom_age" class="hlw-px-3 hlw-h-10 hlw-block hlw-border hlw-rounded hlw-outline hlw-outline-0" placeholder="Tuổi của mẹ" tabindex="0">
            </div>
            <div class="hlw-flex hlw-flex-col hlw-gap-1">
                <input type="text" name="baby_age" class="hlw-px-3 hlw-h-10 hlw-block hlw-border hlw-rounded hlw-outline hlw-outline-0" placeholder="Tuổi của con" tabindex="0">
            </div>
        </div>
        <div class="hlw-flex hlw-flex-col hlw-gap-1">
            <input type="text" name="address" class="hlw-px-3 hlw-h-10 hlw-block hlw-border hlw-rounded hlw-outline hlw-outline-0" placeholder="Địa chỉ" tabindex="0">
        </div>
        <div class="hlw-flex hlw-flex-col hlw-gap-1">
            <textarea name="message" class="hlw-px-3 hlw-py-2 hlw-h-16 hlw-block hlw-border hlw-rounded hlw-outline hlw-outline-0" placeholder="Ghi chú" tabindex="0"></textarea>
        </div>
        <div class="hlw-flex hlw-justify-center">
            <button type="submit" class="hlw-flex hlw-justify-center hlw-items-center hlw-pt-px hlw-px-6 hlw-h-10 hlw-rounded hlw-bg-[#005eac] hlw-text-white hlw-font-bold" tabindex="0">
                Đăng ký tư vấn
            </button>
        </div>
    </form>