body form { opacity: 1.0; } .other-input, form.size-small .other-input { display: inline-block; } .checklist.allow-other > label:last-child > span { display: none; }

Fill Out the Form Below to Verify if Your Insurance will Pay for Treatment

Name

Phone

Who Is Seeking Treatment?

Name of Patient

Date of Birth of Patient

Insurance Company's Name

Insurance Company's Phone Number

Member ID#