Transplant BU > Cloud Pages > API Internal Testing Forms > Pediatric Heart Surgery Traveling Patient - TEST FORM


      <h2>Pediatric Heart Surgery Traveling Patient - Test Form</h2>
      <form action="https://pages.upmc.com/pediatric-heart-surgery-traveling-patient-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>Who Are You Submitting This Request For?</label>
          <select name="submitting_request_for" id="submitting_request_for">
            <option value="" selected="selected">Select One</option>
            <option value="I am submitting this form on behalf of myself.">I am submitting this form on behalf of myself.</option>
            <option value="I am submitting this form on behalf of my child.">I am submitting this form on behalf of my child.</option>
            <option value="I am submitting this form on behalf of my baby who is not born yet.">I am submitting this form on behalf of my baby who is not born yet.</option>
          </select><br><br>

          <label>Diagnosis:</label>
            <select name="diagnosis" id="diagnosis">
              <option value="" selected="selected">Select One</option>
              <option value="Ebstein’s Anomaly">Ebstein’s Anomaly</option>
              <option value="Transposition of the Great Arteries">Transposition of the Great Arteries</option>
              <option value="Hypoplastic Left Heart Syndrome">Hypoplastic Left Heart Syndrome</option>
              <option value="Pulmonary Atresia">Pulmonary Atresia</option>
              <option value="Tricuspid Atresia">Tricuspid Atresia</option>
              <option value="Other/Undiagnosed">Other/Undiagnosed</option>
            </select><br><br>

            <label>Reason for Inquiry:</label>
              <select name="reason_for_inquiry" id="reason_for_inquiry">
                <option value="" selected="selected">Select One</option>
                <option value="Seek a second opinion">Seek a second opinion</option>
                <option value="Request an appointment">Request an appointment</option>
                <option value="Request more information">Request more information</option>
                <option value="Other">Other</option>
              </select><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>
         <input name="submitted" type="hidden" value="true" />
         <input type="submit" value="Submit">
      </form>