CHP BU > CloudPages > API Internal Testing Forms > CCP Share Your Story - TEST FORM


      <h2>CCP Share Your Story - Test Form</h2>
      <form action="https://pages.upmc.com/ccp-shareyourstory-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>Zip Code</label>
         <input type="text" name="zip_code"><br>

         <label>Practice Name</label>
         <input type="text" name="practice_name"><br>

         <label>Provider Name</label>
         <input type="text" name="provider_name"><br>

         <label>Your Care Story</label>
         <textarea type="text" name="comments"></textarea><br>

         <label>Service Line</label>
         <input type="text" name="service_line"><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>