CHP BU > CloudPages > API Internal Testing Forms > CHP Center for Rare Disease Therapy - TEST FORM


      <h2>CHP Center for Rare Disease Therapy - Test Form</h2>
      <form action="https://pages.upmc.com/chp-center-for-rare-disease-therapy-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><br>

         <label>Relationship to Patient</label><br>
         <input type="radio" id="Self" name="patient_relationship" value="Self">
            <label for="Self">Self</label><br>
         <input type="radio" id="Parent/Guardian" name="patient_relationship" value="Parent/Guardian">
            <label for="Parent/Guardian">Parent/Guardian</label><br>
         <input type="radio" id="Family Member" name="patient_relationship" value="Family Member">
            <label for="Family Member">Family Member</label><br>
         <input type="radio" id="Medical Provider" name="patient_relationship" value="Medical Provider">
            <label for="Medical Provider">Medical Provider</label><br>
         <input type="radio" id="Other" name="patient_relationship" value="Other">
            <label for="Other">Other</label><br>

         <label>Relationship to Patient (Other)</label>
         <input type="text" name="patient_relationship_other"><br><br>

         <label>Location of Patient</label><br>
         <input type="radio" id="United States" name="patient_location" value="United States">
            <label for="United States">United States</label><br>
         <input type="radio" id="International" name="patient_location" value="International">
            <label for="International ">International</label><br>

         <label>Location of Patient (State)</label>
         <input type="text" name="patient_location_state"><br>

         <label>Location of Patient (Country)</label>
         <input type="text" name="patient_location_country"><br><br>

         <label>Rare Condition(s) You Are Inquiring About</label>
         <textarea type="text" name="rare_conditions"></textarea><br><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>