Western Psych BU > CloudPages > API Internal Testing Forms > Center for Interventional Psychiatry Contact Form - TEST FORM


      <h2>Center for Interventional Psychiatry Contact Form - Test Form</h2>
      <form action="https://pages.upmc.com/center-for-interventional-psychiatry-contact-form-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>Patient Name</label>
         <input type="text" name="patient_name"><br>
         <label>Phone Number</label>
         <input type="text" name="phone_number"><br>
         <label>State / Province</label>
         <input type="text" name="state"><br>
         <label>Zip Code</label>
         <input type="text" name="zip_code"><br>
         <label>Country</label>
         <input type="text" name="country"><br>

         <label>Best Time to Call:</label><br>
            <input type="radio" id="Morning" name="best_time_to_call" value="Morning">
               <label for="Morning">Morning</label><br>
            <input type="radio" id="Afternoon" name="best_time_to_call" value="Afternoon">
               <label for="Afternoon">Afternoon</label><br>

         <label>I want to:</label>
            <select name="interest" id="interest">
               <option value="" selected="selected">Select One</option>
               <option value="Schedule an appointment">Schedule an appointment</option>
               <option value="Ask a question">Ask a question</option>
               <option value="Request an expert opinion">Request an expert opinion</option>
               <option value="Seek care for a child (pediatric patient)">Seek care for a child (pediatric patient)</option>
               <option value="Other">Other</option>
            </select><br>

         <label>Insurance Provider</label>
         <input type="text" name="insurance_provider"><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>