HVI BU > CloudPages > API Internal Testing Forms > Heart Transplant in WVa - TEST FORM


      <h2>Heart Transplant in WVa - Test Form</h2>
      <form action="https://pages.upmc.com/heart-transplant-wva-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 like to receive communication from UPMC?</label><br>
         <select name="contact_preference" id="contact_preference" multiple>
            <option value="Email">Email</option>
            <option value="Mail">Mail</option>
         </select><br><br>

         <p><strong>If "mail" is chosen from the checkboxes above...</strong></p>
         <label>Street Address 1</label>
         <input type="text" name="street_address_1"><br>
         <label>Street Address 2</label>
         <input type="text" name="street_address_2"><br>
         <label>City</label>
         <input type="text" name="city"><br>
         <label>State</label>
         <input type="text" name="state"><br><br>
         
         
         <label>Region</label>
         <input type="text" name="region"><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>