UPMC BU > Cloud Pages > API Internal Testing Forms > Delivering More Erie Campaign - TEST FORM


      <h2>Delivering More Erie Campaign API - Test Form</h2>
      <form action="https://pages.upmc.com/delivering-more-erie-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>I want to schedule an appointment or would like more information about:</label>
          <select name="interest" id="interest">
            <option value="" selected="selected">Select One</option>
            <option value="Gynecology Well Visit">Gynecology Well Visit</option>
            <option value="Prenatal/Pregnancy">Prenatal/Pregnancy</option>
            <option value="Pelvic Floor Urogynecology">Pelvic Floor Urogynecology</option>
            <option value="Endometriosis">Endometriosis</option>
            <option value="Gynecologic Oncology">Gynecologic Oncology</option>
            <option value="Unsure">Unsure</option>
          </select><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>