Cancer BU > CloudPages > API Internal Testing Forms > Hillman Contact Form - TEST FORM


      <h2>Hillman Contact Form - Test Form</h2>
      <form action="https://pages.upmc.com/hillman-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>

         <label>Reason for Contacting UPMC Hillman Cancer Center</label>
               <select name="interest" id="interest">
                  <option value="" selected="selected">Select One</option>
                  <option value="Careers and Training">Careers and Training</option>
                  <option value="Classes and Events">Classes and Events</option>
                  <option value="Compliments">Compliments</option>
                  <option value="Donating to UPMC Hillman Cancer Center">Donating to UPMC Hillman Cancer Center</option>
                  <option value="Financial Questions">Financial Questions</option>
                  <option value="Medical Records">Medical Records</option>
                  <option value="Patient Experience">Patient Experience</option>
                  <option value="Volunteering at UPMC Hillman Cancer Center">Volunteering at UPMC Hillman Cancer Center</option>
               </select><br>

         <label>Would you like to opt in to marketing communications? (marketing_opt_in checkbox)</label><br>
                <select name="marketing_opt_in" id="marketing_opt_in" multiple>
                    <option value="true">Yes</option>
                </select><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>