UPMC BU > Cloud Pages > API Internal Testing Forms > Patient and Family Council Application Form - TEST FORM


      <h2>Patient and Family Council Application Form - Test Form</h2>
      <form action="https://pages.upmc.com/patient-and-family-council-application-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>Council</label>
         <select name="council" id="council">
            <option value="" selected="selected">Select One</option>
            <option value="UPMC Quality and Patient Experience">UPMC Quality and Patient Experience</option>
            <option value="UPMC Passavant">UPMC Passavant</option>
            <option value="UPMC Presbyterian">UPMC Presbyterian</option>
            <option value="UPMC Shadyside">UPMC Shadyside</option>
            <option value="UPMC St. Margaret">UPMC St. Margaret</option>
         </select><br>

         <label>Why do you want to join the Patient and Family Advisory Council?</label>
            <textarea type="text" name="comments"></textarea><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>