Neurosurgery BU > CloudPages > API Internal Testing Forms > Physician Resources Neuro Traveling Patient Campaign - TEST FORM


      <h2>Physician Resources Neuro Traveling Patient Campaign - Test Form</h2>
      <form action="https://pages.upmc.com/physician-resources-neuro-traveling-patient-campaign-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>Zip Code</label>
         <input type="text" name="zip_code"><br><br>

         <label>Condition</label>
         <select name="condition" id="condition">
            <option value="" selected="selected">Select One</option>
            <option value="Chiari Malformation">Chiari Malformation</option>
            <option value="Epilepsy">Epilepsy</option>
            <option value="Facial Nerve Disorders">Facial Nerve Disorders</option>
            <option value="Pituitary and Skull Base Tumor">Pituitary and Skull Base Tumor</option>
         </select><br><br>

         <label>Is this patient an adult or pediatric patient?</label>
         <select name="patient_type" id="patient_type">
            <option value="" selected="selected">Select One</option>
            <option value="Adult">Adult</option>
            <option value="Pediatric">Pediatric</option>
         </select><br><br>

         <label>Please enter your insurance provider:</label>
         <input type="text" name="insurance_provider"><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>