Ortho BU - CloudPages - API Configurations - CPA Ortho - [Test Form] CPA Ortho Campaign


      <h2>CPA Ortho Campaign - Test Form</h2>
      <form action="https://pages.upmc.com/cpa-ortho-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>
         <label>Location</label>
            <select name="location" id="location">
                <option value="" selected="selected">Select One</option>
               <option value="Annville">Annville</option>
              <option value="Carlisle">Carlisle</option>
              <option value="Enola">Enola</option>
              <option value="Hanover">Hanover</option>
              <option value="Harrisburg">Harrisburg</option>
              <option value="Hershey">Hershey</option>
              <option value="Hummelstown (pediatric orthopaedics)">Hummelstown (pediatric orthopaedics)</option>
              <option value="Lancaster">Lancaster</option>
              <option value="Lebanon">Lebanon</option>
              <option value="Lewisberry">Lewisberry</option>
              <option value="Lititz">Lititz</option>
              <option value="Mechanicsburg">Mechanicsburg</option>
              <option value="Newport">Newport</option>
              <option value="Shippensburg">Shippensburg</option>
                
            </select><br><br>
         
            <label>SMS Opt-In Checkbox<br><em>Select 'True' to recieve SMS Message.</em></label><br>
            <select name="sms_opt_in" id="sms_opt_in" multiple>
                <option value="true">True</option>
                <option value="false">False</option>
            </select><br><br>

            <label>Marketing Opt-In Checkbox<br><em>Select 'True' to recieve SMS Message.</em></label><br>
            <select name="marketing_opt_in" id="marketing_opt_in" multiple>
                <option value="true">True</option>
                <option value="false">False</option>
            </select><br><br>
         
         <label>Region</label>
         <input type="text" name="region"><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>