CHP BU > CloudPages > API Internal Testing Forms > CHP Praise from Patients - TEST FORM


      <h2>CHP Praise from Patients - Test Form</h2>
      <form action="https://pages.upmc.com/chp-praise-from-patients-api-internal-testing-form" method="post">

         <label>First and last name of staff member you would like to recognize</label>
         <input type="text" name="employee_name"><br>
         <label>Employees job title</label>
         <input type="text" name="employee_job_title"><br>
         <label>Unit or Department</label>
         <input type="text" name="department"><br><br>

         <label>Tell us about your experience with this staff member</label>
         <textarea type="text" name="patient_experience"></textarea><br><br>

         <label>Childs name</label>
         <input type="text" name="child_name"><br>
         <label for="patient_visit_date">Date of patients visit</label>
         <input type="date" id="patient_visit_date" name="patient_visit_date"
            value="mm-dd-yyyy"
            min="2023-01-01" max="2024-12-31"><br><br>

         <label>Your Email Address</label>
         <input type="text" name="email_address"><br>
         <label>Your Name</label>
         <input type="text" name="full_name"><br>
         <label>Your Phone Number</label>
         <input type="text" name="phone_number"><br>
         <label>Zip Code</label>
         <input type="text" name="zip_code"><br>
         <label>Township/City of Residence</label>
         <input type="text" name="city"><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>