Ortho BU > CloudPages > API Internal Testing Forms > Somerset Ortho Campaign Form - TEST FORM


      <h2>Somerset Ortho Campaign - Test Form</h2>
      <form action="https://pages.upmc.com/somerset-ortho-campaign-form-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>Choose a Service</label>
            <select name="service" id="service">
                <option value="" selected="selected">Select One</option>
                <option value="Foot and ankle">Foot and ankle</option>
                <option value="General orthopaedics">General orthopaedics</option>
                <option value="Hand, elbow, and shoulder">Hand, elbow, and shoulder</option>
                <option value="Minimally invasive spine surgery">Minimally invasive spine surgery</option>
                <option value="Sports medicine">Sports medicine</option>
            </select><br><br>

        <label>I would like to:</label><br>
            <select name="interest" id="interest" multiple>
                <option value="Request an Appointment">Request an Appointment</option>
                <option value="Service/Treatment Inquiry">Service/Treatment Inquiry</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>Marketing Opt-In Checkbox<br><em>Select 'True' to recieve SMS Message.</em></label><br>
            <select name="marketing_opt_in" id="marketing_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><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>