UPMC BU > CloudPages > API Internal Testing Forms > Colorectal Surgery Campaign - TEST FORM


      <h2>Colorectal Surgery Campaign - Test Form</h2>
      <form action="https://pages.upmc.com/colorectal-surgery-campaign-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>Zip Code</label>
         <input type="text" name="zip_code"><br><br>

         <label>What colorectal conditions are you interested in?</label>
            <select name="interest" id="interest">
               <option value="" selected="selected">Select One</option>
               <option value="Colon Cancer">Colon Cancer</option>
               <option value="Colon Polyps">Colon Polyps</option>
               <option value="Crohn’s Disease">Crohn’s Disease</option>
               <option value="Diverticular Disease/Diverticulitis">Diverticular Disease/Diverticulitis</option>
               <option value="Inflammatory Bowel Disease">Inflammatory Bowel Disease</option>
               <option value="Other">Other</option>
            </select><br><br>

         <label>Are you interested in learning about telemedicine options?</label><br>
            <input type="radio" id="Yes" name="telemedicine" value="Yes">
               <label for="Yes">Yes</label><br>
            <input type="radio" id="No" name="telemedicine" value="No">
               <label for="No">No</label><br><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>