UPMC BU > CloudPages > API Internal Testing Forms > Bloodless Medicine Contact Us - TEST FORM


      <h2>Bloodless Medicine Contact Us - Test Form</h2>
      <form action="https://pages.upmc.com/bloodless-medicine-contact-us-api-internal-testing-form" method="post">
         <label>Email</label>
         <input type="text" name="email_address"><br>
         <label>First Name</label>
         <input type="text" name="first_name"><br>
         <label>Last Name</label>
         <input type="text" name="last_name"><br>
         <label>Phone Number</label>
         <input type="text" name="phone_number"><br>
         
         <label>Comments</label>
            <textarea type="text" name="comments"></textarea><br> 

         <label>Category</label>
         <input type="text" name="category"><br>
         <label>Subcategory</label>
         <input type="text" name="subcategory"><br>
         <input name="submitted" type="hidden" value="true" />
         <input type="submit" value="Submit">
      </form>