Plastic Surgery BU > CloudPages > API Configurations > Cosmetic Surgery Contact Form > Cosmetic Surgery Contact Form - INTERNAL


      <h2>Cosmetic Surgery Contact Form - INTERNAL</h2>
      <form action="https://pages.upmc.com/cosmetic-surgery-contact-form-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>
         <label>Zip Code</label>
         <input type="text" name="zip_code"><br><br>
         
         <label>How would you prefer to be contacted?</label><br>
            <input type="radio" id="Email" name="contact_method" value="Email">
                <label for="Email">Email</label><br>
            <input type="radio" id="Phone" name="contact_method" value="Phone">
                <label for="Phone">Phone</label><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 on product or procedure">Looking for additional information on product or procedure</option>
                <option value="Speak to an expert">Speak to 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>How did you hear about Cosmetic Surgery and Skin Health Center?</label><br>
            <select name="discovery" id="discovery" multiple>
                <option value="Doctor">Doctor</option>
                <option value="Insurance Provider Directory">Insurance Provider Directory</option>
                <option value="Friend/Family Member">Friend/Family Member</option>
                <option value="Patient">Patient</option>
                <option value="Website">Website</option>
                <option value="Yellow Pages">Yellow Pages</option>
                <option value="UPMC Referral Service">UPMC Referral Service</option>
                <option value="Billboard Advertising">Billboard Advertising</option>
                <option value="Magazine/Newspaper Ad">Magazine/Newspaper Ad</option>
                <option value="TV Ad">TV Ad</option>
                <option value="Community Event">Community Event</option>
                <option value="Other">Other</option>
            </select><br><br>

         <label>Category</label>
         <input type="text" name="category"><br>
         <label>Subcategory</label>
         <input type="text" name="subcategory"><br><br>

         <br>
        <div style="background-color:#96B8B9;padding:20px 15px 5px 15px;width:450px;">
          <label><strong>Captcha Score</strong></label>         <input type="text" name="captcha_score"><br>
            <ul>
                <li><strong>0-70</strong> will fire the TY email</li>
                <li><strong>71-80</strong> will fire the hcaptcha verification email</li>
                <li><strong>81 and above</strong> will destroy your life</li>
            </ul>
        </div>
        <br>

         <input name="submitted" type="hidden" value="true" />
         <input type="submit" value="Submit">
      </form>