Cancer BU > Cloud Pages > API Internal Testing Forms > Hillman Footprint Wide Campaign - TEST FORM


      <h2>Hillman Footprint Wide Campaign - Test Form</h2>
      <form action="https://pages.upmc.com/hillman-footprint-wide-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>Preferred Contact Method</label>
          <select name="preferred_contact_method" id="preferred_contact_method">
            <option value="" selected="selected">Select One</option>
            <option value="Email">Email</option>
            <option value="Phone">Phone</option>
          </select><br><br>

          <label>Reason for Inquiry</label>
          <select name="reason_for_inquiry" id="reason_for_inquiry">
            <option value="" selected="selected">Select One</option>
            <option value="Second opinion">Second opinion</option>
            <option value="New diagnosis">New diagnosis</option>
            <option value="Finding an oncologist">Finding an oncologist</option>
            <option value="Clinical trials">Clinical trials</option>
            <option value="Insurance coverage">Insurance coverage</option>
            <option value="Access">Access</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>