CRS BU > CloudPages > API Internal Testing Forms > Rehab Adult Spina Bifida Clinic - TEST FORM


      <h2>Rehab Adult Spina Bifida Clinic - Test Form</h2>
      <form action="https://pages.upmc.com/rehab-adult-spina-bifida-clinic-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>
         <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>