UPMC BU > Cloud Pages > API Internal Testing Forms > Digestive Disorders Center Referring Physicians DDW Sponsorship - TEST FORM


      <h2>Digestive Disorders Center Referring Physicians DDW Sponsorship - Test Form</h2>
      <form action="https://pages.upmc.com/digestive-disorders-center-referring-physicians-ddw-sponsorship-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>Select a Specialty</label>
            <select name="specialty" id="specialty">
                <option value="" selected="selected">Select One</option>
                <option value="Family Medicine">Family Medicine</option>

                <option value="Internal Medicine">Internal Medicine</option>

                <option value="Gastroenterology">Gastroenterology</option>

                <option value="Hepatology">Hepatology</option>

                <option value="Nutrition">Nutrition</option>

                <option value="Other">Other</option>
            </select><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>