Bariatrics BU > CloudPages > API Configurations > Jameson Bariatrics Campaign > Jameson Bariatrics Campaign API Form - Internal Testing


      <h2>UPMC Jameson Baritrics Campaign API - Internal Testing Form</h2>
      <form action="https://pages.upmc.com/jameson-bariatrics-campaign-api-internal-testing" 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 prefer to be contacted via:</label><br>
            <select name="contact_method" id="contact_method" multiple>
                <option value="Phone">Phone</option>
                <option value="Email">Email</option>
            </select><br><br>

            <label>I’m Looking to Make A Change</label>
            <select name="interest_timeframe" id="interest_timeframe">
                <option value="" selected="selected">Select One</option>
                <option value="Now">Now</option>
                <option value="In 3 to 6 Months">In 3 to 6 Months</option>
                <option value="More than 6 Months">More than 6 Months</option>
                <option value="I don’t know, trying to learn more.">I don’t know, trying to learn more.</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>

        <div style="background-color:#96B8B9;padding:20px 15px 5px 15px;width:450px;">
            <label><strong>Captcha Score</strong></label><input type="text" name="captcha_score"><br>
            <ul>
                <li><strong>0-70</strong> will fire the TY email</li>
                <li><strong>71-80</strong> will fire the hcaptcha verification email</li>
                <li><strong>81 and above</strong> will destroy your life</li>
            </ul>
        </div><br><br>

         <input name="submitted" type="hidden" value="true" />
         <input type="submit" value="Submit">
      </form>