@charset "utf-8";

html,
body {
  font-family: Arial, Helvetica, sans-serif;
}

h2 {
  clear: left;
  color: #02205e;
  font-family: "Times New Roman", Times, serif;
  margin-bottom: 5px;
}

h3 {
  clear: left;
  color: #02205e;
  font-family: "Times New Roman", Times, serif;
  margin-bottom: 5px;
}

p {
  margin: 0;
  text-indent: 50px;
}

.hidden {
  display: none;
}

.form_heading img {
  float: left;
  margin-right: 25px;
}

.form_heading #practice_name,
.form_heading #contact_info {
  color: #02205e;
  padding: 5px;
  text-align: center;
  width: 545px;
}

.form_heading #practice_name {
  border-bottom: 1px solid #999;
  float: left;
  font-family: "Times New Roman", Times, serif;
  font-size: 16px;
  font-weight: bold;
}

.form_heading #contact_info {
  float: right;
  font-size: 10px;
}

form {
  color: #000;
  margin: 0 auto;
  position: relative;
  width: 900px;
}

input {
  border: none;
  margin: 0;
}

label {
  float: left;
  margin: 0 1px 0 0;
}

input[type=text] {
  border-bottom: 1px solid #333;
  color: #111;
  float: left;
  font-family: "Courier New", Courier, monospace;
  margin: 0 2px 0 2px;
  padding: 0 0 0 6px;
  font-size: 16px;
}

input[type=submit] {
  background-color: #28a745;
  border: 1px solid #28a745;
  clear: left;
  color: #fff;
  float: right;
  width: 100%;
  padding: 8px 50px;
  bottom: 10px;
  right: 0;
  margin-bottom: 40px;
}

input[type=submit]:hover {
  background-color: #1a692d;
}

input[type=radio] {
  margin-left: 5px;
}

input[type=checkbox] {
  margin-right: 3px;
}

/* FONT AWESOME CHECKBOXES */
input[type="checkbox"] + .fal,
input[type="radio"] + .fal,
input[type="checkbox"] + label > .fal,
input[type="radio"] + label > .fal {
  cursor: pointer;
}

input[type="checkbox"] + .fa-check-square::before,
input[type="radio"] + .fa-check-square::before,
input[type="checkbox"] + label > .fa-check-square::before,
input[type="radio"] + label > .fa-check-square::before {
  content: "\f0c8";
}

input[type="checkbox"]:checked + .fa-check-square::before,
input[type="radio"]:checked + .fa-check-square::before,
input[type="checkbox"]:checked + label > .fa-check-square::before,
input[type="radio"]:checked + label > .fa-check-square::before {
  content: "\f14a";
}

.large-check {
  font-size: 1.25rem;
}

.form_heading {
  margin: 0 0 25px 0;
  overflow: hidden;
}

.yes_line_short {
  border-bottom: 1px solid rgb(214, 214, 214);
  width: 740px;
  margin-top: -2px;
}

.yes_line {
  border-bottom: 1px solid rgb(214, 214, 214);
  width: 760px;
  margin-top: -2px;
}

.yes_line_long {
  border-bottom: 1px solid rgb(214, 214, 214);
  width: 790px;
  margin-top: -2px;
}

.under_label {
  color: #666;
  font-size: 12px;
  margin: 2px 0 0 0;
  text-transform: uppercase;
}

#patient_last_name {
  width: 215px;
}

#patient_middle_initial,
#financial_middle_initial,
#medical_middle_initial {
  width: 50px;
}

#patient_first_name {
  width: 200px;
}

#referred_by {
  width: 225px;
}

#patient_address,
#financial_address {
  width: 681px;
}

#apt_number,
#financial_apt_number {
  width: 100px;
}

#patient_city,
#financial_city,
.insurance_city {
  width: 405px;
}

#patient_state,
#financial_state,
.insurance_state {
  width: 260px;
}

#patient_zip,
#financial_zip,
.insurance_zip {
  width: 118px;
}

.phone_area_code {
  width: 50px;
}

#home_phone,
#financial_home_phone {
  width: 280px;
}

#work_phone,
#financial_work_phone {
  width: 292px;
}

#cell_phone {
  width: 292px;
}

#patient_email,
#financial_email {
  width: 400px;
}

#employer,
#financial_employer {
  width: 372px;
}

#occupation,
#spouse_occupation,
#financial_spouse_occupation {
  width: 217px;
}

#how_long,
#spouse_how_long,
#financial_how_long,
#financial_spouse_how_long {
  width: 78px;
}

#drivers_license_number,
#financial_drivers_license_number {
  width: 320px;
}

#license_exp,
#financial_license_exp {
  width: 394px;
}

#social_number {
  width: 190px;
}

#birthdate {
  width: 236px;
}

#age {
  width: 95px;
}

#student_school {
  width: 551px;
}

#emergency_name {
  width: 255px;
}

.emergency_home_phone_area_code,
.emergency_cell_phone_area_code {
  width: 50px;
}

#emergency_home_phone,
#emergency_cell_phone {
  width: 125px;
}

#emergency_address {
  width: 395px;
}

#emergency_city {
  width: 200px;
}

#emergency_state {
  width: 40px;
}

#emergency_zip {
  width: 85px;
}

#financial_last_name {
  width: 390px;
}

#financial_first_name {
  width: 386px;
}

#financial_cell_phone {
  width: 294px;
}

#financial_occupation {
  width: 370px;
}

#financial_social_number {
  width: 327px;
}

#financial_birthdate {
  width: 383px;
}

#financial_relation,
.insurance_relation {
  width: 462px;
}

#patient_resides {
  width: 553px;
}

.insurance_patient_name {
  width: 315px;
}

.insurance_patient_dob {
  width: 277px;
}

.insurance_patient_social {
  width: 247px;
}

.insurance_subscriber_id {
  width: 330px;
}

.insurance_group_id {
  width: 390px;
}

.insurance_employer {
  width: 374px;
}

.insurance_employer_phone {
  width: 264px;
}

.insurance_carrier {
  width: 324px;
}

.insurance_carrier_phone {
  width: 278px;
}

.insurance_teamster_name {
  width: 683px;
}

.insurance_claim_address {
  width: 723px;
}

.responsible_signature {
  width: 460px;
}

.responsible_relationship {
  width: 740px;
}

.responsible_witness {
  width: 526px;
}

.yearly_update {
  float: left;
  font-weight: bold;
  margin: 0 80px;
}

#medical_last_name,
#medical_first_name {
  width: 262px;
}

#medical_date {
  width: 163px;
}

#medical_height {
  width: 397px;
}

#medical_weight {
  width: 390px;
}

.last_menstruation {
  width: 660px;
  float: right !important;
}

.question,
.question2 {
  float: left;
}

.question2 {
  margin-left: 25px;
}

.question span,
.question2 span {
  float: left;
  width: 25px;
}

.yes_no {
  float: right;
}

#last_physical {
  width: 560px;
}

#current_conditions {
  width: 608px;
}

#illness_operation {
  width: 539px;
}

#hospital_problem {
  width: 608px;
}

#bleeding_explain {
  width: 648px;
}

#what_drug {
  width: 675px;
}

#still_taking_this {
  width: 635px;
}

#current_medications,
#allergies,
#why_see_us {
  float: left;
  margin-left: 50px;
  width: 845px;
}

#current_medications {
  height: 300px;
}

#allergies {
  height: 140px;
}

#why_see_us {
  height: 70px;
  margin-left: 25px;
  width: 870px;
}

#refusal_name {
  width: 595px;
}
#permission_name {
  width: 510px;
  margin-right:10px;
}
#permission_relation {
  width: 224px;
}

#patient_signature,
#doctor_signature {
  width: 523px;
}


@media print {
  input[type=submit] {
    display: none;
  }

  .print-none {
    display: none;
  }
}