Ortho BU > Cloud Pages > API Internal Testing Forms > Ortho Sports Medicine Contact Form - TEST FORM


      <h2>Ortho Sports Medicine Contact Form - Test Form</h2>
      <form action="https://pages.upmc.com/ortho-sportsmed-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><br><br><br>
         
         <label>I'm looking for:</label>
            <select name="interest" id="interest">
              <option value="" selected="selected">Select One</option>
              <option value="Orthopaedic services">Orthopaedic services</option>
              <option value="Sports medicine services">Sports medicine services</option>
            </select><br><br><br>

         <span><strong>-- ORTHO (if 'Orthopaedic services' chosen from the field above) --</strong></span><br><br>

         <label>Choose a service <strong>(ortho only)</strong></label>
            <select name="ortho_service" id="ortho_service">
              <option value="" selected="selected">Select One</option>
              <option value="Foot and ankle">Foot and ankle</option>
              <option value="Fracture care">Fracture care</option>
              <option value="General orthopaedics">General orthopaedics</option>
              <option value="Hand, elbow, and shoulder">Hand, elbow, and shoulder</option>
              <option value="Hip or knee">Hip or knee</option>
              <option value="Joint replacement">Joint replacement</option>
              <option value="Musculoskeletal oncology">Musculoskeletal oncology</option>
              <option value="Pediatric orthopaedics">Pediatric orthopaedics</option>
              <option value="Podiatric surgery">Podiatric surgery</option>
              <option value="Spine surgery">Spine surgery</option>
              <option value="Trauma">Trauma</option>
            </select><br><br>

         <label>Preferred location of services <strong>(ortho only)</strong></label>
            <select name="ortho_service_location" id="ortho_service_location">
              <option value="" selected="selected">Select One</option>
              <option value="Bedford, Blair, and Cambria Counties">Bedford, Blair, and Cambria Counties</option>
              <option value="Chautauqua County">Chautauqua County</option>
              <option value="Cumberland, Dauphin, Franklin, Lancaster, Lebanon, and York Counties">Cumberland, Dauphin, Franklin, Lancaster, Lebanon, and York Counties</option>
              <option value="Crawford, Erie, and Warren Counties">Crawford, Erie, and Warren Counties</option>
              <option value="Allegheny, Armstrong, Beaver, Butler, Washington, and Westmoreland Counties">Allegheny, Armstrong, Beaver, Butler, Washington, and Westmoreland Counties</option>
              <option value="Lawrence and Mercer Counties">Lawrence and Mercer Counties</option>
              <option value="Somerset County">Somerset County</option>
              <option value="Clarion and Venango Counties">Clarion and Venango Counties</option>
              <option value="Lycoming, Potter, and Tioga Counties">Lycoming, Potter, and Tioga Counties</option>
            </select><br><br><br><br>


         <span><strong>-- SPORTS MEDICINE (if 'Sports medicine services' chosen from the field above) --</strong></span><br><br>

         <label>Choose a service <strong>(sports med only)</strong></label>
            <select name="sportsmed_service" id="sportsmed_service">
              <option value="" selected="selected">Select One</option>
              <option value="Sports medicine (physician services)">Sports medicine (physician services)</option>
              <option value="Sports performance">Sports performance</option>
              <option value="Sports nutrition">Sports nutrition</option>
              <option value="Concussion">Concussion</option>
            </select><br><br>

         <label>Preferred location of services <strong>(sports med only)</strong></label>
            <select name="sportsmed_service_location" id="sportsmed_service_location">
              <option value="" selected="selected">Select One</option>
              <option value="Bedford, Blair, and Cambria Counties">Bedford, Blair, and Cambria Counties</option>
              <option value="Chautauqua County">Chautauqua County</option>
              <option value="Cumberland, Dauphin, Franklin, Lancaster, Lebanon, and York Counties">Cumberland, Dauphin, Franklin, Lancaster, Lebanon, and York Counties</option>
              <option value="Crawford, Erie, and Warren Counties">Crawford, Erie, and Warren Counties</option>
              <option value="Allegheny, Armstrong, Beaver, Butler, Washington, and Westmoreland Counties">Allegheny, Armstrong, Beaver, Butler, Washington, and Westmoreland Counties</option>
              <option value="Lawrence and Mercer Counties">Lawrence and Mercer Counties</option>
              <option value="Somerset County">Somerset County</option>
              <option value="Clarion and Venango Counties">Clarion and Venango Counties</option>
              <option value="Lycoming, Potter, and Tioga Counties">Lycoming, Potter, and Tioga Counties</option>
            </select><br><br>
        
       <label>What sports performance services are you looking for? <strong>(sports med only)</strong></label>
         <input type="text" name="sports_performance_services"><br><br>
        <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>

        <br>
        <div style="background-color:#96B8B9;padding:20px 15px 5px 15px;width:450px;">
          <label><strong>Captcha Score</strong></label>         <input type="text" name="captcha_score"><br>
        <ul>
          <li><strong>0-70</strong> will fire the TY email</li>
  <li><strong>71-80</strong> will fire the hcaptcha verification email</li>
  <li><strong>81 and above</strong> will destroy your life</li>
        </ul>
        </div>
        <br><br>


         <input name="submitted" type="hidden" value="true" />
         <input type="submit" value="Submit">
      </form>