UPMC BU > CloudPages > API Internal Testing Forms > Rehab Institute Wheelchair Wash - TEST FORM


      <h2>Rehab Institute Wheelchair Wash - Test Form</h2>
      <form action="https://pages.upmc.com/rehab-institute-wheelchair-wash-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>Caregiver First Name</label>
         <input type="text" name="caregiver_first_name"><br>
         <label>Caregiver Last Name</label>
         <input type="text" name="caregiver_last_name"><br>
         <label>Caregiver Email </label>
         <input type="text" name="caregiver_email_address"><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>