Transplant BU > CloudPages > API Internal Testing Forms > LDLT Life Changing Liver Campaign 2022 Relaunch - TEST FORM


      <h2>LDLT Life Changing Liver Campaign 2022 Relaunch - Test Form</h2>
      <form action="https://pages.upmc.com/ldlt-life-changing-liver-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>Interest</label>
            <select name="interest_reason" id="interest_reason">
                <option value="" selected="selected">Select One</option>
                <option value="Receiving a Liver Transplant">Receiving a Liver Transplant</option>
                <option value="Become a Living Donor">Become a Living Donor</option>
            </select><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>