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


      <h2>Hillman Pancreatic Cancer Contact Form - Test Form</h2>
      <form action="https://pages.upmc.com/hillman-pancreatic-cancer-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>Patient Name</label>
         <input type="text" name="patient_name"><br>

         <label>Contact Method</label>
            <select name="contact_method" id="contact_method">
               <option value="" selected="selected">Select One</option>
               <option value="Email">Email</option>
               <option value="Phone">Phone</option>
            </select><br>

        <label>Diagnosis</label>
            <select name="diagnosis" id="diagnosis">
               <option value="" selected="selected">Select One</option>
               <option value="Pancreatic Cancer">Pancreatic Cancer</option>
               <option value="Pancreatitis">Pancreatitis</option>
               <option value="Pancreatic Cysts">Pancreatic Cysts</option>
               <option value="Other">Other</option>
            </select><br>

        <label>Reason for Inquiry:</label>
            <select name="reason_for_inquiry" id="reason_for_inquiry">
               <option value="" selected="selected">Select One</option>
               <option value="General Information">General Information</option>
               <option value="Schedule an Appointment">Schedule an Appointment </option>
               <option value="Second Opinion">Second Opinion</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>