Transplant BU > CloudPages > API Internal Testing Forms > Hamot Kidney Transplant Campaign  - TEST FORM


      <h2>Hamot Kidney Transplant Campaign  - Test Form</h2>
      <form action="https://pages.upmc.com/hamot-kidney-transplant-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>Are you interested in receiving a kidney transplant or in becoming a living donor?</label>
            <select name="interest" id="interest">
               <option value="" selected="selected">Select One</option>
               <option value="Becoming a living donor">Becoming a living donor</option>
               <option value="Receiving a kidney transplant">Receiving a kidney transplant</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>
         <input name="submitted" type="hidden" value="true" />
         <input type="submit" value="Submit">
      </form>