CHP BU > Cloud Pages > API Internal Testing Forms > CHP PIDC Contact Us - TEST FORM


      <h2>CHP PIDC Contact Us - Test Form</h2>
      <form action="https://pages.upmc.com/chp-pidc-contact-us-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>
            <select name="relationship_to_patient" id="relationship_to_patient">
                <option value="" selected="selected">Select One</option>
                <option value="Self">Self</option>
                <option value="Parent/Guardian">Parent/Guardian</option>
                <option value="Family Member">Family Member</option>
                <option value="Medical Provider">Medical Provider</option>
                <option value="Other">Other</option>
            </select><br><br>

         <label>Location of Patient</label>
            <select name="patient_location" id="patient_location">
                <option value="" selected="selected">Select One</option>
                <option value="United States">United States</option>
                <option value="International">International</option>
            </select><br>

         <label>If United States, specify State:</label>
            <input type="text" name="state"><br>
         <label>If International, specify Country:</label>
            <input type="text" name="country"><br><br>

         <label>Reason for Inquiry</label>
            <select name="reason_for_inquiry" id="reason_for_inquiry">
                <option value="" selected="selected">Select One</option>
                <option value="Schedule an appointment">Schedule an appointment</option>
                <option value="Looking for additional information">Looking for additional information</option>
                <option value="Connect with an expert">Connect with an expert</option>
                <option value="Other">Other</option>
            </select><br><br>

         <label>Additional questions or comments</label>
            <textarea type="text" name="comments"></textarea><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>