Senior Services BU > Cloud Pages > API Internal Testing Forms > GUIDE Model Interest Form API - TEST FORM


      <h2>GUIDE Model Interest Form API - Test Form</h2>
      <form action="https://pages.upmc.com/senior-services-guide-model-interest-form-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><br>

         <label>Preferred Contact Method</label>
            <select name="preferred_contact_method" id="preferred_contact_method">
                <option value="" selected="selected">Select One</option>
                <option value="Email">Email</option>
                <option value="Phone">Phone</option>
            </select><br><br>

         <label>What best describes you?</label>
         <select name="personal_description" id="personal_description">
                <option value="" selected="selected">Select One</option>
                <option value="Patient">Patient (or prospective patient)</option>
                <option value="Caregiver">Caregiver</option>
                <option value="Other">Other</option>
            </select><br><br>

         <label>If a caregiver, what is your relationship to the patient?</label>
         <input type="text" name="relationship_to_patient"><br><br>

         <label>Patient's Name (First and Last)</label>
         <input type="text" name="patient_name"><br><br>

         <label>Subject of Inquiry</label>
         <input type="text" name="inquiry"><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>