UPMC BU > CloudPages > API Configurations > Magee Brand Campaign > Magee Brand Campaign 2024 - TEST FORM


      <h2>Magee Brand Campaign (with 2026 updates) - Test Form</h2>
      <form action="https://pages.upmc.com/magee-brand-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 want to schedule an appointment or would like more information about:</label>
            <select name="interest" id="interest">
               <option value="" selected="selected">Select One</option>
               <option value="Gynecology Well Visit">Gynecology Well Visit</option>
               <option value="Prenatal/Pregnancy">Prenatal/Pregnancy</option>
               <option value="Fertility">Fertility</option>
               <option value="Pelvic Floor (Urogynecology)">Pelvic Floor (Urogynecology)</option>
               <option value="Endometriosis">Endometriosis</option>
               <option value="Midlife Health">Midlife Health</option>
               <option value="Unsure">Unsure</option>
            </select><br><br>

        <label>SMS Opt-In Checkbox<br><em>Select 'True' to recieve SMS Message.</em></label><br>
            <select name="sms_opt_in" id="sms_opt_in" multiple>
                <option value="true">True</option>
                <option value="false">False</option>
            </select><br><br>
         
         <label>Service Line</label>
         <input type="text" name="service_line"><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" /><br>
         <input type="submit" value="Submit">
      </form>