UPMC BU > CloudPages > API Internal Testing Forms > Lewsiburg Campaign (updated version for 2023) - TEST FORM


      <h2>Lewsiburg Campaign (updated version for 2023) - Test Form</h2>
      <form action="https://pages.upmc.com/lewisburg-campaign-2023-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>What service are you interested in?</label>
         <select name="interest" id="interest">
            <option value="" selected="selected">Select One</option>
            <option value="Service 1">Service 1</option>
            <option value="Service 2">Service 2</option>
            <option value="Service 3">Service 3</option>
            <option value="Service 4">Service 4</option>
            <option value="Service 5">Service 5</option>
         </select><br><br>
         
         <label>I would like to:</label><br>
         <select name="request" id="request" multiple>
            <option value="Request an Appointment">Request an Appointment</option>
            <option value="Inquire about a Service/Treatment">Inquire about a Service/Treatment</option>
         </select><br><br>

         <label>I agree to receive marketing emails from UPMC.<br> I understand that I may opt out of receiving such communications at any time.</label><br>
         <select name="marketing_opt_in" id="marketing_opt_in" multiple>
         <option value="true">true</option>
         </select><br><br>

         <label>Region</label>
         <input type="text" name="region"><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>
         <input name="submitted" type="hidden" value="true" />
         <input type="submit" value="Submit">
      </form>