CHP BU > CloudPages > API Internal Testing Forms > Hillman Here for You - TEST FORM

      <h2>Hillman Here for You - Test Form</h2>
      <form action="https://pages.upmc.com/hillman-here-for-you-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><br>

         <label>Preferred Contact Method (Enter 'Email' or 'Phone')</label>
         <input type="text" name="contact_method"><br><br>

         <label for="reason_for_inquiry">Reason for Inquiry</label>
            <select name="reason_for_inquiry" id="reason_for_inquiry">
              <option value="">Select One</option>
            <option value="A new diagnosis">A new diagnosis</option>
            <option value="Second Opinion">Second Opinion</option>
            <option value="Finding an oncologist">Finding an oncologist</option>
            <option value="Clinical trials">Clinical trials</option>
            <option value="Insurance Coverage and Access">Insurance Coverage and Access</option>
            </select><br><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><br>
         <input name="submitted" type="hidden" value="true" />
         <input type="submit" value="Submit">
      </form>