Bariatrics BU > Cloud Pages > API Internal Testing Forms > Magee Bariatrics Campaign - TEST FORM


      <h2>Magee Bariatrics Campaign - Test Form</h2>
      <form action="https://pages.upmc.com/magee-bariatrics-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>I am interested in:</label><br>
          <select name="interest" id="interest" multiple>
            <option value="Surgical Weight Loss Procedures">Surgical Weight Loss Procedures</option>
            <option value="Non-surgical Weight Loss Procedures">Non-surgical Weight Loss Procedures</option>
            <option value="Medical Weight Loss (medication)">Medical Weight Loss (medication)</option>
            <option value="Lifestyle Weight Loss (nutrition, exercise)">Lifestyle Weight Loss (nutrition, exercise)</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>
         <input name="submitted" type="hidden" value="true" />
         <input type="submit" value="Submit">
      </form>