Submit Form with JSON and Headers

Offer:
Email:
Phone:
First Name:
Last Name:
Description:
illness (Select multiple):
Asthma
Bladder cancer
Blood cancer
Colon cancer
COPD
Esophageal cancer
Kidney cancer
Laryngeal cancer
Leukemia
Liver cancer
Lung cancer
Lymphoma
Mesothelioma
Pancreatic cancer
Prostate cancer
Pulmonary fibrosis
Stomach cancer
Testicular cancer
Throat cancer
Other
No Illness

Smoker (Select one):
Injury (Select one):
injury_time (Select one):

Hidden Fields

landing_page_url
ip_address
traffic_source
referrer
lander_variant
campaign_name
adset_name
ad_name
source_site
placement
fb_clid
utm_source
utm_content
keyword
campaign_id
adset_id
lander_id
fb_ad_id
google_clickid_s2
voluum_clickId
http_user_agent
gc_id
fb_acct_id
hyrostracker