CHP BU > CloudPages > API Internal Testing Forms > CHP Physician Relations (2023) - TEST FORM


      <h2>CHP Physician Relations (2023) - Test Form</h2>
      <form action="https://pages.upmc.com/chp-physician-relations-api-internal-tesing-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>Practice</label>
         <input type="text" name="practice"><br>
         <label>Role</label>
         <input type="text" name="role"><br><br>

         <label>Would you like to:</label><br>
         <select name="request" id="request" multiple>
            <option value="Receive the newsletter">Receive the newsletter</option>
            <option value="Get contacted by a liaison">Get contacted by a liaison</option>
         </select><br><br>

         <label><strong>Receive the newsletter</strong> <br> <em>(enter 'True' or 'False' matching your selection from the 'Would you like to:' field above)</em></label>
         <br><input type="text" name="request_newsletter"><br><br>

         <label><strong>Get contacted by a liaison</strong> <br> <em>(enter 'True' or 'False' matching your selection from the 'Would you like to:' field above)</em></label>
         <br><input type="text" name="request_liaison"><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>