CHP BU > CloudPages > API Internal Testing Forms > CHP IBD Center Contact Form - TEST FORM


      <h2>CHP IBD Center Contact Form - Test Form</h2>
      <form action="https://pages.upmc.com/chp-ibd-center-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>Phone Number</label>
         <input type="text" name="phone_number"><br>
         <label>Zip Code</label>
         <input type="text" name="zip_code"><br><br>

         <label>Who Are You Submitting This Request For?</label><br>
            <select name="submit_request_for" id="submit_request_for" multiple>
              <option value="I am submitting this form on behalf of myself.">I am submitting this form on behalf of myself.</option>
              <option value="I am submitting this form on behalf of my child.">I am submitting this form on behalf of my child.</option>
              <option value="I am a referring physician submitting this form on behalf of a patient.">I am a referring physician submitting this form on behalf of a patient.</option>
            </select><br><br>

         <label>Reason for Inquiry</label><br>
            <select name="reason_for_inquiry" id="reason_for_inquiry" multiple>
              <option value="Seek a second opinion">Seek a second opinion</option>
              <option value="Request an appointment">Request an appointment</option>
              <option value="Request more information">Request more information</option>
              <option value="Other">Other</option>
            </select><br><br>

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

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