UPMC BU > CloudPages > API Internal Testing Forms > UPMC Breast Cancer Program Contact Form - TEST FORM


      <h2>UPMC Breast Cancer Program Contact Form - Test Form</h2>
      <form action="https://pages.upmc.com/upmc-breast-cancer-program-contact-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>

         <label>How do you wish to be contacted?</label><br>
            <input type="radio" id="Email" name="contact_method" value="Email">
               <label for="Email">Email</label><br>
            <input type="radio" id="Phone" name="contact_method" value="Phone">
               <label for="Phone">Phone</label><br>

         <label>Interest</label>
            <select name="interest" id="interest">
               <option value="" selected="selected">Select One</option>
               <option value="Treatment Options">Treatment Options</option>
               <option value="Clinical Trials">Clinical Trials</option>
               <option value="Resources">Resources</option>
               <option value="Directions">Directions</option>
               <option value="Referrals">Referrals</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>