UPMC BU > CloudPages > API Internal Testing Forms > Imaging Contact Us - TEST FORM


      <h2>Imaging Contact Us - Test Form</h2>
      <form action="https://pages.upmc.com/imaging-contact-us-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>I Want to Schedule:</label>
            <select name="schedule" id="schedule">
               <option value="" selected="selected">Select One</option>
               <option value="Ultrasound">Ultrasound</option>
               <option value="Fluoroscopy">Fluoroscopy</option>
               <option value="CT">CT</option>
               <option value="MRI">MRI</option>
               <option value="PET Scan">PET Scan</option>
               <option value="Nuclear Medicine">Nuclear Medicine</option>
               <option value="Interventional Radiology">Interventional Radiology</option>
               <option value="DXA">DXA</option>
               <option value="Mammography">Mammography</option>
               <option value="Other">Other</option>
            </select><br><br>

         <label>Preferred Appointment Time:</label><br>
            <input type="radio" id="Morning" name="appointment_time" value="Morning">
               <label for="Morning">Morning</label><br>
            <input type="radio" id="Afternoon" name="appointment_time" value="Afternoon">
               <label for="Afternoon">Afternoon</label><br>
            <input type="radio" id="Evening" name="appointment_time" value="Evening">
               <label for="Evening">Evening</label><br><br>

         <label>Best Time to Call:</label><br>
            <input type="radio" id="8:30am to noon" name="call_time" value="8:30 am to noon">
               <label for="8:30 am to noon">8:30 am to noon</label><br>
            <input type="radio" id="1 to 5pm" name="call_time" value="1 to 5pm">
               <label for="1 to 5pm">1 to 5pm</label><br><br>

         <label>Comments</label>
            <textarea type="text" name="comments"></textarea><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>