Medical Reputation BU > CloudPages > API Internal Testing Forms > Physician Resources Newsletter - TEST FORM


      <h2>Physician Resources Newsletter - Test Form</h2>
      <form action="https://pages.upmc.com/physician-resources-newsletter-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>

         <label>Your Specialty</label>
         <select name="physician_specialty" id="physician_specialty">
            <option value="" selected="selected">Select One</option>
            <option value="Child and Adolescent Psychiatry">Child and Adolescent Psychiatry</option>
            <option value="Endocrinology">Endocrinology</option>
            <option value="Gastroenterology">Gastroenterology</option>
            <option value="Geriatrics">Geriatrics</option>
            <option value="Gynecology">Gynecology</option>
            <option value="Heart and Vascular">Heart and Vascular</option>
            <option value="Kidney Disorders">Kidney Disorders</option>
            <option value="Neonatology">Neonatology</option>
            <option value="Neurology">Neurology</option>
            <option value="Neurosurgery">Neurosurgery</option>
            <option value="Oncology">Oncology</option>
            <option value="Ophthalmology">Ophthalmology</option>
            <option value="Orthopaedic Surgery">Orthopaedic Surgery</option>
            <option value="Other">Other</option>
            <option value="Otolaryngology">Otolaryngology</option>
            <option value="Pediatric Cardiology and Heart Surgery">Pediatric Cardiology and Heart Surgery</option>
            <option value="Pediatric Diabetes and Endocrinology ">Pediatric Diabetes and Endocrinology </option>
            <option value="Pediatric Gastroenterology and GI Surgery">Pediatric Gastroenterology and GI Surgery</option>
            <option value="Pediatric Nephrology">Pediatric Nephrology</option>
            <option value="Pediatric Neurology and Neurosurgery">Pediatric Neurology and Neurosurgery</option>
            <option value="Pediatric Oncology">Pediatric Oncology</option>
            <option value="Pediatric Orthopaedics">Pediatric Orthopaedics</option>
            <option value="Pediatric Pulmonology">Pediatric Pulmonology</option>
            <option value="Pediatric Urology">Pediatric Urology</option>
            <option value="Psychiatry">Psychiatry</option>
            <option value="Pulmonology">Pulmonology</option>
            <option value="Rehabilitation">Rehabilitation</option>
            <option value="Rheumatology">Rheumatology</option>
            <option value="Thoracic Surgery">Thoracic Surgery</option>
            <option value="Transplantation">Transplantation</option>
            <option value="Urology">Urology</option>
         </select><br>

         <label>Your Role</label>
         <select name="physician_role" id="physician_role">
            <option value="" selected="selected">Select One</option>
            <option value="Physician">Physician</option>
            <option value="Resident/Fellow">Resident/Fellow</option>
            <option value="Medical Student">Medical Student</option>
            <option value="Nurse/Advanced Practice Nurse">Nurse/Advanced Practice Nurse</option>
            <option value="Optometrist">Optometrist</option>
            <option value="Physician Assistant">Physician Assistant</option>
            <option value="Pharmacist">Pharmacist</option>
            <option value="Psychologist">Psychologist</option>
            <option value="Health Business Administration">Health Business Administration</option>
            <option value="Other Health Care Provider">Other Health Care Provider</option>
         </select><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>