Transplant BU > Cloud Pages > API Internal Testing Forms > (2024-2025) Transplant Contact Us - TEST FORM


      <h2>(2024-2025) Transplant Contact Us - Test Form</h2>
      <form action="https://pages.upmc.com/transplant-contact-us-2024-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>
        
         <p>a bunch of fields...</p>

            <label>Which type of treatment fits your request? (<em>treatment_type</em>)</label>
                <select name="treatment_type" id="treatment_type">
                    <option value="" selected="selected">Select One</option>
                    <option value="Heart Transplant/VAD">Heart Transplant/VAD</option>
                    <option value="Intestinal (small bowel) Transplant">Intestinal (small bowel) Transplant</option>
                    <option value="Lung Transplant">Lung Transplant</option>
                    <option value="Liver Transplant">Liver Transplant</option>
                    <option value="Kidney Transplant">Kidney Transplant</option>
                    <option value="Pancreas Transplant">Pancreas Transplant</option>
                </select><br><br>

            <label>Which evaluation and transplant location are you interested in? (<em>kidney_transplant_location</em>)</label> <select name="kidney_transplant_location" id="kidney_transplant_location">
                <option value="" selected="selected">Select One</option>
                <option value="UPMC Montefiore">UPMC Montefiore</option>
                <option value="UPMC Harrisburg">UPMC Harrisburg</option>
                <option value="UPMC Hamot">UPMC Hamot</option>
            </select><br>
            <span style="font-style:italic;color:red;">Note: This field will now <strong>only</strong> appear if 'Kidney Transplant' is selected from above. ONLY select from this dropdown menu if you chose 'Kidney Transplant'.</span>
           <br>

         <p>a bunch of fields...</p>

         <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>