CHP BU > CloudPages > API Internal Testing Forms > CHP Patient Relations Contact Form - TEST FORM


      <h2>CHP Patient Relations Contact Form - Test Form</h2>
      <form action="https://pages.upmc.com/chp-patient-relations-contact-form-api-internal-testing-form" method="post">

         <label>Date(s) of Hospital Visit</label>
         <input type="text" name="visit_date"><br>

         <label>Hospital Unit/Clinic where your child received care (i.e., 8A)</label>
         <input type="text" name="hospital_unit"><br><br>

         <label>Location</label>
         <select name="location" id="location">
            <option value="" selected="selected">Select One</option>
            <option value="UPMC Children’s Hospital of Pittsburgh – Main Campus">UPMC Children’s Hospital of Pittsburgh – Main Campus</option>
            <option value="UPMC Children’s East – Monroeville">UPMC Children’s East – Monroeville</option>
            <option value="UPMC Children’s North – Wexford">UPMC Children’s North – Wexford</option>
            <option value="UPMC Children’s Pine Center – Wexford">UPMC Children’s Pine Center – Wexford</option>
         </select><br><br>

         <label>Child’s first and last name</label>
         <input type="text" name="childs_full_name"><br>

         <label>Your first and last name</label>
         <input type="text" name="full_name"><br><br>

         <label>Relationship to the patient</label>
         <select name="relationship_to_patient" id="relationship_to_patient">
            <option value="" selected="selected">Select One</option>
            <option value="Parent">Parent</option>
            <option value="Legal Guardian">Legal Guardian</option>
            <option value="Grandparent">Grandparent</option>
            <option value="Aunt/Uncle">Aunt/Uncle</option>
            <option value="Sibling">Sibling</option>
            <option value="Spouse">Spouse</option>
            <option value="Partner">Partner</option>
            <option value="Other">Other</option>
         </select><br><br>

         <label>Email</label>
         <input type="text" name="email_address"><br>

         <label>Phone Number</label>
         <input type="text" name="phone_number"><br><br>
         
         <label>Your Comments</label>
         <textarea type="text" name="comments"></textarea><br> <br>

         <label>Check here to opt in to receiving a monthly eNewsletter from UPMC Children’s</label><br>
         <select name="marketing_opt_in" id="marketing_opt_in" multiple>
         <option value="true">true</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>
         <input name="submitted" type="hidden" value="true" />
         <input type="submit" value="Submit">
      </form>