UPMC BU > CloudPages > API Internal Testing Forms > IBD Unite Form 2023 - TEST FORM


      <h2>IBD Unite Form 2023 - Test Form</h2>
      <form action="https://pages.upmc.com/ibd-unite-form-2023-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>City</label>
         <input type="text" name="city"><br>
         <label>State</label>
         <input type="text" name="state"><br>
         <label>Zip Code</label>
         <input type="text" name="zip_code"><br><br>

         <label>Will you seek nursing credits?</label><br>
            <input type="radio" id="Yes" name="nursing_credits" value="Yes">
               <label for="Yes">Yes</label><br>
            <input type="radio" id="No" name="nursing_credits" value="No">
               <label for="No">No</label><br><br>

         <label>Will you seek registered dietitian credits?</label><br>
            <input type="radio" id="Yes" name="dietitian_credits" value="Yes">
               <label for="Yes">Yes</label><br>
            <input type="radio" id="No" name="dietitian_credits" value="No">
               <label for="No">No</label><br><br>

         <label>Attending via</label><br>
            <input type="radio" id="In-Person" name="attending_via" value="In-Person">
               <label for="In-Person">In-Person</label><br>
            <input type="radio" id="Zoom" name="attending_via" value="Zoom">
               <label for="Zoom">Zoom</label><br><br>

         <label>Service Line</label>
         <input type="text" name="service_line"><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>