CHP BU > CloudPages > API Internal Testing Forms > CHP Neurovascular Center of Excellence Contact Us Form - TEST FORM


      <h2>CHP Neurovascular Center of Excellence Contact Us Form - Test Form</h2>
      <form action="https://pages.upmc.com/chp-neurovascular-center-of-excellence-contact-us-api-internal-testing-form" method="post">

        <label>Who Are You Submitting This Request For?</label><br>
         <input type="radio" id="I am submitting this form on behalf of myself." name="submitting_request_for" value="I am submitting this form on behalf of myself.">
           <label for="I am submitting this form on behalf of myself.">I am submitting this form on behalf of myself.</label><br>
         <input type="radio" id="I am submitting this form on behalf of my child." name="submitting_request_for" value="I am submitting this form on behalf of my child.">
           <label for="I am submitting this form on behalf of my child.">I am submitting this form on behalf of my child.</label><br>
         <input type="radio" id="I am submitting this form on behalf of my baby who is not born yet." name="submitting_request_for" value="I am submitting this form on behalf of my baby who is not born yet.">
           <label for="I am submitting this form on behalf of my baby who is not born yet.">I am submitting this form on behalf of my baby who is not born yet.</label><br>
         <input type="radio" id="I am a referring physician submitting this form on behalf of a patient." name="submitting_request_for" value="I am a referring physician submitting this form on behalf of a patient.">
           <label for="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.</label><br><br>

         <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>Country</label>
         <input type="text" name="country"><br><br>

         <label>Reason for Inquiry</label><br>
         <input type="radio" id="Seek a second opinion" name="reason_for_inquiry" value="Seek a second opinion">
           <label for="Seek a second opinion">Seek a second opinion</label><br>
         <input type="radio" id="Request an appointment" name="reason_for_inquiry" value="Request an appointment">
           <label for="Request an appointment">Request an appointment</label><br>
         <input type="radio" id="Request more information" name="reason_for_inquiry" value="Request more information">
           <label for="Request more information">Request more information</label><br>
         <input type="radio" id="Other" name="reason_for_inquiry" value="Other">
           <label for="Other">Other</label><br><br>
        
        <label>Insurance</label><br>
         <input type="radio" id="Yes" name="insurance" value="Yes">
           <label for="Yes">Yes</label><br>
         <input type="radio" id="No" name="insurance" value="No">
           <label for="No">No</label><br><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>