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| Current File : /home/udaipurk/public_html/websites/form/eversana.html |
<html lang="en">
<head>
<meta charset="utf-8">
<title>Eversana</title>
<meta name="viewport" content="width=device-width,initial-scale=1">
<!--<link rel="icon" type="image/x-icon" href="">-->
<link href="https://fonts.googleapis.com/css?family=Poppins:300,400,500,600,700%7CRoboto:300,400,500,600,700"
rel="stylesheet">
<!--<link href="https://fonts.googleapis.com/icon?family=Material+Icons" rel="stylesheet">-->
<link rel="stylesheet" href="https://fonts.googleapis.com/css?family=Roboto:300,400,500">
<link rel="stylesheet" href="https://cdn.jsdelivr.net/npm/bootstrap@5.1.0/dist/css/bootstrap.min.css"
integrity="sha384-KyZXEAg3QhqLMpG8r+8fhAXLRk2vvoC2f3B09zVXn8CA5QIVfZOJ3BCsw2P0p/We" crossorigin="anonymous">
<!-- <link rel="stylesheet" id="layout-styles-anchor" href="/css/splash-screen.css">
<script crossorigin="anonymous"
src="https://polyfill.io/v3/polyfill.min.js?features=es2017%2Cdefault%2Ces2015%2Ces2016%2CIntl"></script>
<link href="https://cdn.syncfusion.com/ej2/material.css" rel="stylesheet">
<link href="/static/css/5.ccbb370d.chunk.css" rel="stylesheet">
<link href="/static/css/10.ecffae5e.chunk.css" rel="stylesheet">
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<link href="/static/css/11.49ba4d42.chunk.css" rel="stylesheet">
<link href="/static/css/main~493df0b3.3af0bc18.chunk.css" rel="stylesheet"> -->
<meta name="react-film" content="version=3.0.0">
<meta name="react-scroll-to-bottom:version" content="4.1.0">
<meta name="web-speech-cognitive-services" content="version=undefined">
<meta name="botframework-directlinespeech:version" content="4.13.0">
<meta name="botframework-webchat:bundle:variant" content="full">
<meta name="botframework-webchat:bundle:version" content="4.13.0">
<meta name="botframework-webchat:core:version" content="4.13.0">
<meta name="botframework-webchat:ui:version" content="4.13.0">
<style data-jss="" data-meta="MuiSvgIcon">
.inputText {
font-size: 18px;
width: 200px;
height: 35px;
}
.gender_field{
padding: 0 10px;
}
.dob_label{
background: #fafafa;
}
.MuiFormGroup-root.allergies_group{
flex-direction: row;
flex-wrap: nowrap;
align-items: center;
}
.MuiFormGroup-root.allergies_group .MuiFormLabel-root{
margin-right: 20px;
}
.note-align {
margin-top: 30px;
}
img, svg {
max-width: 100%;
}
.note {
text-align: center;
color: #0077C0;
font-weight: 600;
}
.MuiSvgIcon-root {
fill: currentColor;
width: 1em;
height: 1em;
display: inline-block;
font-size: 1.5rem;
transition: fill 200ms cubic-bezier(0.4, 0, 0.2, 1) 0ms;
flex-shrink: 0;
user-select: none;
}
.flex-nowrap {
flex-wrap: nowrap;
}
.MuiSvgIcon-colorPrimary {
color: #54b847;
}
.MuiSvgIcon-colorSecondary {
color: #0077C0;
}
.MuiSvgIcon-colorAction {
color: rgba(0, 0, 0, 0.54);
}
.MuiSvgIcon-colorError {
color: #f44336;
}
.MuiSvgIcon-colorDisabled {
color: rgba(0, 0, 0, 0.26);
}
.MuiSvgIcon-fontSizeInherit {
font-size: inherit;
}
.MuiSvgIcon-fontSizeSmall {
font-size: 1.25rem;
}
.MuiSvgIcon-fontSizeLarge {
font-size: 2.1875rem;
}
</style>
<style data-jss="" data-meta="MuiCollapse">
.MuiCollapse-root {
height: 0;
overflow: hidden;
transition: height 300ms cubic-bezier(0.4, 0, 0.2, 1) 0ms;
}
.MuiCollapse-entered {
height: auto;
overflow: visible;
}
.MuiCollapse-hidden {
visibility: hidden;
}
.MuiCollapse-wrapper {
display: flex;
}
.MuiCollapse-wrapperInner {
width: 100%;
}
</style>
<style data-jss="" data-meta="MuiPaper">
.MuiPaper-root {
color: rgba(0, 0, 0, 0.87);
transition: box-shadow 300ms cubic-bezier(0.4, 0, 0.2, 1) 0ms;
background-color: #fff;
}
.MuiPaper-rounded {
border-radius: 4px;
}
.MuiPaper-outlined {
border: 1px solid rgba(0, 0, 0, 0.12);
}
.MuiPaper-elevation0 {
box-shadow: none;
}
.MuiPaper-elevation1 {
box-shadow: 0px 2px 1px -1px rgba(0, 0, 0, 0.2), 0px 1px 1px 0px rgba(0, 0, 0, 0.14), 0px 1px 3px 0px rgba(0, 0, 0, 0.12);
}
.MuiPaper-elevation2 {
box-shadow: 0px 3px 1px -2px rgba(0, 0, 0, 0.2), 0px 2px 2px 0px rgba(0, 0, 0, 0.14), 0px 1px 5px 0px rgba(0, 0, 0, 0.12);
}
.MuiPaper-elevation3 {
box-shadow: 0px 3px 3px -2px rgba(0, 0, 0, 0.2), 0px 3px 4px 0px rgba(0, 0, 0, 0.14), 0px 1px 8px 0px rgba(0, 0, 0, 0.12);
}
.MuiPaper-elevation4 {
box-shadow: 0px 2px 4px -1px rgba(0, 0, 0, 0.2), 0px 4px 5px 0px rgba(0, 0, 0, 0.14), 0px 1px 10px 0px rgba(0, 0, 0, 0.12);
}
.MuiPaper-elevation5 {
box-shadow: 0px 3px 5px -1px rgba(0, 0, 0, 0.2), 0px 5px 8px 0px rgba(0, 0, 0, 0.14), 0px 1px 14px 0px rgba(0, 0, 0, 0.12);
}
.MuiPaper-elevation6 {
box-shadow: 0px 3px 5px -1px rgba(0, 0, 0, 0.2), 0px 6px 10px 0px rgba(0, 0, 0, 0.14), 0px 1px 18px 0px rgba(0, 0, 0, 0.12);
}
.MuiPaper-elevation7 {
box-shadow: 0px 4px 5px -2px rgba(0, 0, 0, 0.2), 0px 7px 10px 1px rgba(0, 0, 0, 0.14), 0px 2px 16px 1px rgba(0, 0, 0, 0.12);
}
.MuiPaper-elevation8 {
box-shadow: 0px 5px 5px -3px rgba(0, 0, 0, 0.2), 0px 8px 10px 1px rgba(0, 0, 0, 0.14), 0px 3px 14px 2px rgba(0, 0, 0, 0.12);
}
.MuiPaper-elevation9 {
box-shadow: 0px 5px 6px -3px rgba(0, 0, 0, 0.2), 0px 9px 12px 1px rgba(0, 0, 0, 0.14), 0px 3px 16px 2px rgba(0, 0, 0, 0.12);
}
.MuiPaper-elevation10 {
box-shadow: 0px 6px 6px -3px rgba(0, 0, 0, 0.2), 0px 10px 14px 1px rgba(0, 0, 0, 0.14), 0px 4px 18px 3px rgba(0, 0, 0, 0.12);
}
.MuiPaper-elevation11 {
box-shadow: 0px 6px 7px -4px rgba(0, 0, 0, 0.2), 0px 11px 15px 1px rgba(0, 0, 0, 0.14), 0px 4px 20px 3px rgba(0, 0, 0, 0.12);
}
.MuiPaper-elevation12 {
box-shadow: 0px 7px 8px -4px rgba(0, 0, 0, 0.2), 0px 12px 17px 2px rgba(0, 0, 0, 0.14), 0px 5px 22px 4px rgba(0, 0, 0, 0.12);
}
.MuiPaper-elevation13 {
box-shadow: 0px 7px 8px -4px rgba(0, 0, 0, 0.2), 0px 13px 19px 2px rgba(0, 0, 0, 0.14), 0px 5px 24px 4px rgba(0, 0, 0, 0.12);
}
.MuiPaper-elevation14 {
box-shadow: 0px 7px 9px -4px rgba(0, 0, 0, 0.2), 0px 14px 21px 2px rgba(0, 0, 0, 0.14), 0px 5px 26px 4px rgba(0, 0, 0, 0.12);
}
.MuiPaper-elevation15 {
box-shadow: 0px 8px 9px -5px rgba(0, 0, 0, 0.2), 0px 15px 22px 2px rgba(0, 0, 0, 0.14), 0px 6px 28px 5px rgba(0, 0, 0, 0.12);
}
.MuiPaper-elevation16 {
box-shadow: 0px 8px 10px -5px rgba(0, 0, 0, 0.2), 0px 16px 24px 2px rgba(0, 0, 0, 0.14), 0px 6px 30px 5px rgba(0, 0, 0, 0.12);
}
.MuiPaper-elevation17 {
box-shadow: 0px 8px 11px -5px rgba(0, 0, 0, 0.2), 0px 17px 26px 2px rgba(0, 0, 0, 0.14), 0px 6px 32px 5px rgba(0, 0, 0, 0.12);
}
.MuiPaper-elevation18 {
box-shadow: 0px 9px 11px -5px rgba(0, 0, 0, 0.2), 0px 18px 28px 2px rgba(0, 0, 0, 0.14), 0px 7px 34px 6px rgba(0, 0, 0, 0.12);
}
.MuiPaper-elevation19 {
box-shadow: 0px 9px 12px -6px rgba(0, 0, 0, 0.2), 0px 19px 29px 2px rgba(0, 0, 0, 0.14), 0px 7px 36px 6px rgba(0, 0, 0, 0.12);
}
.MuiPaper-elevation20 {
box-shadow: 0px 10px 13px -6px rgba(0, 0, 0, 0.2), 0px 20px 31px 3px rgba(0, 0, 0, 0.14), 0px 8px 38px 7px rgba(0, 0, 0, 0.12);
}
.MuiPaper-elevation21 {
box-shadow: 0px 10px 13px -6px rgba(0, 0, 0, 0.2), 0px 21px 33px 3px rgba(0, 0, 0, 0.14), 0px 8px 40px 7px rgba(0, 0, 0, 0.12);
}
.MuiPaper-elevation22 {
box-shadow: 0px 10px 14px -6px rgba(0, 0, 0, 0.2), 0px 22px 35px 3px rgba(0, 0, 0, 0.14), 0px 8px 42px 7px rgba(0, 0, 0, 0.12);
}
.MuiPaper-elevation23 {
box-shadow: 0px 11px 14px -7px rgba(0, 0, 0, 0.2), 0px 23px 36px 3px rgba(0, 0, 0, 0.14), 0px 9px 44px 8px rgba(0, 0, 0, 0.12);
}
.MuiPaper-elevation24 {
box-shadow: 0px 11px 15px -7px rgba(0, 0, 0, 0.2), 0px 24px 38px 3px rgba(0, 0, 0, 0.14), 0px 9px 46px 8px rgba(0, 0, 0, 0.12);
}
</style>
<style data-jss="" data-meta="MuiAccordion">
.MuiAccordion-root {
position: relative;
transition: margin 150ms cubic-bezier(0.4, 0, 0.2, 1) 0ms;
}
.MuiAccordion-root:before {
top: -1px;
left: 0;
right: 0;
height: 1px;
content: "";
opacity: 1;
position: absolute;
transition: opacity 150ms cubic-bezier(0.4, 0, 0.2, 1) 0ms, background-color 150ms cubic-bezier(0.4, 0, 0.2, 1) 0ms;
background-color: rgba(0, 0, 0, 0.12);
}
.MuiAccordion-root.Mui-expanded {
margin: 16px 0;
}
.MuiAccordion-root.Mui-disabled {
background-color: rgba(0, 0, 0, 0.12);
}
.MuiAccordion-root.Mui-expanded+.MuiAccordion-root:before {
display: none;
}
.MuiAccordion-root.Mui-expanded:first-child {
margin-top: 0;
}
.MuiAccordion-root.Mui-expanded:last-child {
margin-bottom: 0;
}
.MuiAccordion-root.Mui-expanded:before {
opacity: 0;
}
.MuiAccordion-root:first-child:before {
display: none;
}
.MuiAccordion-rounded {
border-radius: 0;
}
.MuiAccordion-rounded:first-child {
border-top-left-radius: 4px;
border-top-right-radius: 4px;
}
.MuiAccordion-rounded:last-child {
border-bottom-left-radius: 4px;
border-bottom-right-radius: 4px;
}
@supports (-ms-ime-align: auto) {
.MuiAccordion-rounded:last-child {
border-bottom-left-radius: 0;
border-bottom-right-radius: 0;
}
}
</style>
<style data-jss="" data-meta="MuiAccordionDetails">
.MuiAccordionDetails-root {
/*display: flex;*/
padding: 8px 16px 16px;
}
</style>
<style data-jss="" data-meta="MuiTouchRipple">
.MuiTouchRipple-root {
top: 0;
left: 0;
right: 0;
bottom: 0;
z-index: 0;
overflow: hidden;
position: absolute;
border-radius: inherit;
pointer-events: none;
}
.MuiTouchRipple-ripple {
opacity: 0;
position: absolute;
}
.MuiTouchRipple-rippleVisible {
opacity: 0.3;
animation: MuiTouchRipple-keyframes-enter 550ms cubic-bezier(0.4, 0, 0.2, 1);
transform: scale(1);
}
.MuiTouchRipple-ripplePulsate {
animation-duration: 200ms;
}
.MuiTouchRipple-child {
width: 100%;
height: 100%;
display: block;
opacity: 1;
border-radius: 50%;
background-color: currentColor;
}
.MuiTouchRipple-childLeaving {
opacity: 0;
animation: MuiTouchRipple-keyframes-exit 550ms cubic-bezier(0.4, 0, 0.2, 1);
}
.MuiTouchRipple-childPulsate {
top: 0;
left: 0;
position: absolute;
animation: MuiTouchRipple-keyframes-pulsate 2500ms cubic-bezier(0.4, 0, 0.2, 1) 200ms infinite;
}
@-webkit-keyframes MuiTouchRipple-keyframes-enter {
0% {
opacity: 0.1;
transform: scale(0);
}
100% {
opacity: 0.3;
transform: scale(1);
}
}
@-webkit-keyframes MuiTouchRipple-keyframes-exit {
0% {
opacity: 1;
}
100% {
opacity: 0;
}
}
@-webkit-keyframes MuiTouchRipple-keyframes-pulsate {
0% {
transform: scale(1);
}
50% {
transform: scale(0.92);
}
100% {
transform: scale(1);
}
}
</style>
<style data-jss="" data-meta="MuiButtonBase">
.MuiButtonBase-root {
color: inherit;
border: 0;
cursor: pointer;
margin: 0;
display: inline-flex;
outline: 0;
padding: 0;
position: relative;
align-items: center;
user-select: none;
border-radius: 0;
vertical-align: middle;
-moz-appearance: none;
justify-content: center;
text-decoration: none;
background-color: transparent;
-webkit-appearance: none;
-webkit-tap-highlight-color: transparent;
}
.MuiButtonBase-root::-moz-focus-inner {
border-style: none;
}
.MuiButtonBase-root.Mui-disabled {
cursor: default;
pointer-events: none;
}
@media print {
.MuiButtonBase-root {
-webkit-print-color-adjust: exact;
}
}
</style>
<style data-jss="" data-meta="MuiIconButton">
.MuiIconButton-root {
flex: 0 0 auto;
color: rgba(0, 0, 0, 0.54);
padding: 12px;
overflow: visible;
font-size: 1.5rem;
text-align: center;
transition: background-color 150ms cubic-bezier(0.4, 0, 0.2, 1) 0ms;
border-radius: 50%;
}
.MuiIconButton-root:hover {
background-color: rgba(0, 0, 0, 0.04);
}
.MuiIconButton-root.Mui-disabled {
color: rgba(0, 0, 0, 0.26);
background-color: transparent;
}
@media (hover: none) {
.MuiIconButton-root:hover {
background-color: transparent;
}
}
.MuiIconButton-edgeStart {
margin-left: -12px;
}
.MuiIconButton-sizeSmall.MuiIconButton-edgeStart {
margin-left: -3px;
}
.MuiIconButton-edgeEnd {
margin-right: -12px;
}
.MuiIconButton-sizeSmall.MuiIconButton-edgeEnd {
margin-right: -3px;
}
.MuiIconButton-colorInherit {
color: inherit;
}
.MuiIconButton-colorPrimary {
color: #54b847;
}
.MuiIconButton-colorPrimary:hover {
background-color: rgba(84, 184, 71, 0.04);
}
@media (hover: none) {
.MuiIconButton-colorPrimary:hover {
background-color: transparent;
}
}
.MuiIconButton-colorSecondary {
color: #0077C0;
}
.MuiIconButton-colorSecondary:hover {
background-color: rgba(0, 119, 192, 0.04);
}
@media (hover: none) {
.MuiIconButton-colorSecondary:hover {
background-color: transparent;
}
}
.MuiIconButton-sizeSmall {
padding: 3px;
font-size: 1.125rem;
}
.MuiIconButton-label {
width: 100%;
display: flex;
align-items: inherit;
justify-content: inherit;
}
</style>
<style data-jss="" data-meta="MuiAccordionSummary">
.MuiAccordionSummary-root {
display: flex;
padding: 0px 16px;
min-height: 48px;
transition: min-height 150ms cubic-bezier(0.4, 0, 0.2, 1) 0ms, background-color 150ms cubic-bezier(0.4, 0, 0.2, 1) 0ms;
}
.MuiAccordionSummary-root:hover:not(.Mui-disabled) {
cursor: pointer;
}
.MuiAccordionSummary-root.Mui-expanded {
min-height: 64px;
padding-bottom: 0;
}
.MuiAccordionSummary-root.Mui-focused,
.MuiAccordionSummary-root.Mui-focusVisible {
background-color: rgba(0, 0, 0, 0.12);
}
.MuiAccordionSummary-root.Mui-disabled {
opacity: 0.38;
}
.MuiAccordionSummary-content {
margin: 12px 0;
display: flex;
flex-grow: 1;
transition: margin 150ms cubic-bezier(0.4, 0, 0.2, 1) 0ms;
}
.MuiAccordionSummary-content.Mui-expanded {
margin: 20px 0;
}
.MuiAccordionSummary-expandIcon {
transform: rotate(0deg);
transition: transform 150ms cubic-bezier(0.4, 0, 0.2, 1) 0ms;
}
.MuiAccordionSummary-expandIcon:hover {
background-color: transparent;
}
.MuiAccordionSummary-expandIcon.Mui-expanded {
transform: rotate(180deg);
}
</style>
<style data-jss="" data-meta="MuiTypography">
.MuiTypography-root {
margin: 0;
}
.makeStyles-itemContents-83 .MuiFormControlLabel-root{
margin-bottom: 10px;
}
.MuiTypography-body2 {
font-size: 0.875rem;
font-family: "Roboto", "Helvetica", "Arial", sans-serif;
font-weight: 400;
line-height: 1.43;
letter-spacing: 0.01071em;
}
.MuiTypography-body1 {
font-size: 14px;
font-family: "Roboto", "Helvetica", "Arial", sans-serif;
font-weight: 400;
line-height: 1.5;
letter-spacing: 0.00938em;
}
.MuiTypography-caption {
font-size: 0.75rem;
font-family: "Roboto", "Helvetica", "Arial", sans-serif;
font-weight: 400;
line-height: 1.66;
letter-spacing: 0.03333em;
}
.MuiTypography-button {
font-size: 0.875rem;
font-family: "Roboto", "Helvetica", "Arial", sans-serif;
font-weight: 500;
line-height: 1.75;
letter-spacing: 0.02857em;
text-transform: uppercase;
}
.MuiTypography-h1 {
font-size: 6rem;
font-family: "Roboto", "Helvetica", "Arial", sans-serif;
font-weight: 300;
line-height: 1.167;
letter-spacing: -0.01562em;
}
.MuiTypography-h2 {
font-size: 3.75rem;
font-family: "Roboto", "Helvetica", "Arial", sans-serif;
font-weight: 300;
line-height: 1.2;
letter-spacing: -0.00833em;
}
.MuiTypography-h3 {
font-size: 3rem;
font-family: "Roboto", "Helvetica", "Arial", sans-serif;
font-weight: 400;
line-height: 1.167;
letter-spacing: 0em;
}
.MuiTypography-h4 {
font-size: 2.125rem;
font-family: "Roboto", "Helvetica", "Arial", sans-serif;
font-weight: 400;
line-height: 1.235;
letter-spacing: 0.00735em;
}
.MuiTypography-h5 {
font-size: 1.5rem;
font-family: "Roboto", "Helvetica", "Arial", sans-serif;
font-weight: 400;
line-height: 1.334;
letter-spacing: 0em;
}
.MuiTypography-h6 {
font-size: 1.25rem;
font-family: "Roboto", "Helvetica", "Arial", sans-serif;
font-weight: 500;
line-height: 1.6;
letter-spacing: 0.0075em;
}
.MuiTypography-subtitle1 {
font-size: 1rem;
font-family: "Roboto", "Helvetica", "Arial", sans-serif;
font-weight: 400;
line-height: 1.75;
letter-spacing: 0.00938em;
}
.MuiTypography-subtitle2 {
font-size: 0.875rem;
font-family: "Roboto", "Helvetica", "Arial", sans-serif;
font-weight: 500;
line-height: 1.57;
letter-spacing: 0.00714em;
}
.MuiTypography-overline {
font-size: 0.75rem;
font-family: "Roboto", "Helvetica", "Arial", sans-serif;
font-weight: 400;
line-height: 2.66;
letter-spacing: 0.08333em;
text-transform: uppercase;
}
.MuiTypography-srOnly {
width: 1px;
height: 1px;
overflow: hidden;
position: absolute;
}
.MuiTypography-alignLeft {
text-align: left;
}
.MuiTypography-alignCenter {
text-align: center;
}
.MuiTypography-alignRight {
text-align: right;
}
.MuiTypography-alignJustify {
text-align: justify;
}
.MuiTypography-noWrap {
overflow: hidden;
white-space: nowrap;
text-overflow: ellipsis;
}
.MuiTypography-gutterBottom {
margin-bottom: 0.35em;
}
.MuiTypography-paragraph {
margin-bottom: 16px;
}
.MuiTypography-colorInherit {
color: inherit;
}
.MuiTypography-colorPrimary {
color: #54b847;
}
.MuiTypography-colorSecondary {
color: #0077C0;
}
.MuiTypography-colorTextPrimary {
color: rgba(0, 0, 0, 0.87);
}
.MuiTypography-colorTextSecondary {
color: rgba(0, 0, 0, 0.54);
}
.MuiTypography-colorError {
color: #f44336;
}
.MuiTypography-displayInline {
display: inline;
}
.MuiTypography-displayBlock {
display: block;
}
</style>
<style data-jss="" data-meta="PrivateSwitchBase">
.PrivateSwitchBase-root-49 {
padding: 5px;
}
.PrivateSwitchBase-input-52 {
top: 0;
left: 8px;
width: 52%;
cursor: inherit;
height: 100%;
margin: 0;
/*opacity: 0;*/
padding: 0;
z-index: 1;
position: absolute;
}
</style>
<style data-jss="" data-meta="MuiCheckbox">
.MuiCheckbox-root {
color: rgba(0, 0, 0, 0.54);
}
.MuiCheckbox-colorPrimary.Mui-checked {
color: #54b847;
}
.MuiCheckbox-colorPrimary.Mui-disabled {
color: rgba(0, 0, 0, 0.26);
}
.MuiCheckbox-colorPrimary.Mui-checked:hover {
background-color: rgba(84, 184, 71, 0.04);
}
@media (hover: none) {
.MuiCheckbox-colorPrimary.Mui-checked:hover {
background-color: transparent;
}
}
.MuiCheckbox-colorSecondary.Mui-checked {
color: #0077C0;
}
.MuiCheckbox-colorSecondary.Mui-disabled {
color: rgba(0, 0, 0, 0.26);
}
.MuiCheckbox-colorSecondary.Mui-checked:hover {
background-color: rgba(0, 119, 192, 0.04);
}
@media (hover: none) {
.MuiCheckbox-colorSecondary.Mui-checked:hover {
background-color: transparent;
}
}
</style>
<style data-jss="" data-meta="MuiDialog">
@media print {
.MuiDialog-root {
position: absolute !important;
}
}
.MuiDialog-scrollPaper {
display: flex;
align-items: center;
justify-content: center;
}
.MuiDialog-scrollBody {
overflow-x: hidden;
overflow-y: auto;
text-align: center;
}
.MuiDialog-scrollBody:after {
width: 0;
height: 100%;
content: "";
display: inline-block;
vertical-align: middle;
}
.MuiDialog-container {
height: 100%;
outline: 0;
}
@media print {
.MuiDialog-container {
height: auto;
}
}
.MuiDialog-paper {
margin: 32px;
position: relative;
overflow-y: auto;
}
@media print {
.MuiDialog-paper {
box-shadow: none;
overflow-y: visible;
}
}
.MuiDialog-paperScrollPaper {
display: flex;
max-height: calc(100% - 64px);
flex-direction: column;
}
.MuiDialog-paperScrollBody {
display: inline-block;
text-align: left;
vertical-align: middle;
}
.MuiDialog-paperWidthFalse {
max-width: calc(100% - 64px);
}
.MuiDialog-paperWidthXs {
max-width: 444px;
}
@media (max-width:507.95px) {
.MuiDialog-paperWidthXs.MuiDialog-paperScrollBody {
max-width: calc(100% - 64px);
}
}
.MuiDialog-paperWidthSm {
max-width: 600px;
}
@media (max-width:663.95px) {
.MuiDialog-paperWidthSm.MuiDialog-paperScrollBody {
max-width: calc(100% - 64px);
}
}
.MuiDialog-paperWidthMd {
max-width: 960px;
}
@media (max-width:1023.95px) {
.MuiDialog-paperWidthMd.MuiDialog-paperScrollBody {
max-width: calc(100% - 64px);
}
}
.MuiDialog-paperWidthLg {
max-width: 1280px;
}
@media (max-width:1343.95px) {
.MuiDialog-paperWidthLg.MuiDialog-paperScrollBody {
max-width: calc(100% - 64px);
}
}
.MuiDialog-paperWidthXl {
max-width: 1920px;
}
@media (max-width:1983.95px) {
.MuiDialog-paperWidthXl.MuiDialog-paperScrollBody {
max-width: calc(100% - 64px);
}
}
.MuiDialog-paperFullWidth {
width: calc(100% - 64px);
}
.MuiDialog-paperFullScreen {
width: 100%;
height: 100%;
margin: 0;
max-width: 100%;
max-height: none;
border-radius: 0;
}
.MuiDialog-paperFullScreen.MuiDialog-paperScrollBody {
margin: 0;
max-width: 100%;
}
</style>
<style data-jss="" data-meta="MuiInputBase">
@-webkit-keyframes mui-auto-fill {}
@-webkit-keyframes mui-auto-fill-cancel {}
.MuiInputBase-root {
color: rgba(0, 0, 0, 0.87);
cursor: text;
display: inline-flex;
position: relative;
font-size: 1rem;
box-sizing: border-box;
align-items: center;
font-family: "Roboto", "Helvetica", "Arial", sans-serif;
font-weight: 400;
line-height: 1.1876em;
letter-spacing: 0.00938em;
}
.MuiInputBase-root.Mui-disabled {
color: rgba(0, 0, 0, 0.38);
cursor: default;
}
.MuiInputBase-multiline {
padding: 6px 0 7px;
}
.MuiInputBase-multiline.MuiInputBase-marginDense {
padding-top: 3px;
}
.MuiInputBase-fullWidth {
width: 100%;
}
.MuiInputBase-input {
font: inherit;
color: currentColor;
width: 100%;
border: 0;
height: 1.1876em;
margin: 0;
display: block;
padding: 6px 0 7px;
min-width: 0;
background: none;
box-sizing: content-box;
animation-name: mui-auto-fill-cancel;
letter-spacing: inherit;
animation-duration: 10ms;
-webkit-tap-highlight-color: transparent;
}
.MuiInputBase-input::-webkit-input-placeholder {
color: currentColor;
opacity: 0.42;
transition: opacity 200ms cubic-bezier(0.4, 0, 0.2, 1) 0ms;
}
.MuiInputBase-input::-moz-placeholder {
color: currentColor;
opacity: 0.42;
transition: opacity 200ms cubic-bezier(0.4, 0, 0.2, 1) 0ms;
}
.MuiInputBase-input:-ms-input-placeholder {
color: currentColor;
opacity: 0.42;
transition: opacity 200ms cubic-bezier(0.4, 0, 0.2, 1) 0ms;
}
.MuiInputBase-input::-ms-input-placeholder {
color: currentColor;
opacity: 0.42;
transition: opacity 200ms cubic-bezier(0.4, 0, 0.2, 1) 0ms;
}
.MuiInputBase-input:focus {
outline: 0;
}
.MuiInputBase-input:invalid {
box-shadow: none;
}
.MuiInputBase-input::-webkit-search-decoration {
-webkit-appearance: none;
}
.MuiInputBase-input.Mui-disabled {
opacity: 1;
}
.MuiInputBase-input:-webkit-autofill {
animation-name: mui-auto-fill;
animation-duration: 5000s;
}
label[data-shrink=false]+.MuiInputBase-formControl .MuiInputBase-input::-webkit-input-placeholder {
opacity: 0 !important;
}
label[data-shrink=false]+.MuiInputBase-formControl .MuiInputBase-input::-moz-placeholder {
opacity: 0 !important;
}
label[data-shrink=false]+.MuiInputBase-formControl .MuiInputBase-input:-ms-input-placeholder {
opacity: 0 !important;
}
label[data-shrink=false]+.MuiInputBase-formControl .MuiInputBase-input::-ms-input-placeholder {
opacity: 0 !important;
}
label[data-shrink=false]+.MuiInputBase-formControl .MuiInputBase-input:focus::-webkit-input-placeholder {
opacity: 0.42;
}
label[data-shrink=false]+.MuiInputBase-formControl .MuiInputBase-input:focus::-moz-placeholder {
opacity: 0.42;
}
label[data-shrink=false]+.MuiInputBase-formControl .MuiInputBase-input:focus:-ms-input-placeholder {
opacity: 0.42;
}
label[data-shrink=false]+.MuiInputBase-formControl .MuiInputBase-input:focus::-ms-input-placeholder {
opacity: 0.42;
}
.MuiInputBase-inputMarginDense {
padding-top: 3px;
}
.MuiInputBase-inputMultiline {
height: auto;
resize: none;
padding: 0;
}
.MuiInputBase-inputTypeSearch {
-moz-appearance: textfield;
-webkit-appearance: textfield;
}
</style>
<style data-jss="" data-meta="MuiFormControl">
.MuiFormControl-root {
border: 0;
margin: 0;
display: inline-flex;
padding: 0;
position: relative;
min-width: 0;
flex-direction: column;
vertical-align: top;
}
.MuiFormControl-marginNormal {
margin-top: 16px;
margin-bottom: 8px;
}
.MuiFormControl-marginDense {
margin-top: 8px;
margin-bottom: 4px;
}
.MuiFormControl-fullWidth {
width: 100%;
}
</style>
<style data-jss="" data-meta="MuiFormControlLabel">
.MuiFormControlLabel-root {
cursor: pointer;
display: inline-flex;
align-items: center;
margin-left: -11px;
margin-right: 16px;
vertical-align: middle;
-webkit-tap-highlight-color: transparent;
}
.MuiFormControlLabel-root.Mui-disabled {
cursor: default;
}
.MuiFormControlLabel-labelPlacementStart {
margin-left: 16px;
margin-right: -11px;
flex-direction: row-reverse;
}
.MuiFormControlLabel-labelPlacementTop {
margin-left: 16px;
flex-direction: column-reverse;
}
.MuiFormControlLabel-labelPlacementBottom {
margin-left: 16px;
flex-direction: column;
}
.MuiFormControlLabel-label.Mui-disabled {
color: rgba(0, 0, 0, 0.38);
}
</style>
<style data-jss="" data-meta="MuiFormGroup">
.MuiFormGroup-root {
display: flex;
flex-wrap: wrap;
flex-direction: column;
}
.MuiFormGroup-row {
flex-direction: row;
}
</style>
<style data-jss="" data-meta="MuiFormHelperText">
.MuiFormHelperText-root {
color: rgba(0, 0, 0, 0.54);
margin: 0;
font-size: 0.75rem;
margin-top: 3px;
text-align: left;
font-family: "Roboto", "Helvetica", "Arial", sans-serif;
font-weight: 400;
line-height: 1.66;
letter-spacing: 0.03333em;
}
.MuiFormHelperText-root.Mui-disabled {
color: rgba(0, 0, 0, 0.38);
}
.MuiFormHelperText-root.Mui-error {
color: #f44336;
}
.MuiFormHelperText-marginDense {
margin-top: 4px;
}
.MuiFormHelperText-contained {
margin-left: 14px;
margin-right: 14px;
}
</style>
<style data-jss="" data-meta="MuiFormLabel">
.MuiFormLabel-root {
color: rgba(0, 0, 0, 0.54);
padding: 0;
font-size: 1rem;
font-family: "Roboto", "Helvetica", "Arial", sans-serif;
font-weight: 400;
line-height: 1;
letter-spacing: 0.00938em;
}
.MuiFormLabel-root.Mui-focused {
color: #54b847;
}
.MuiFormLabel-root.Mui-disabled {
color: rgba(0, 0, 0, 0.38);
}
.MuiFormLabel-root.Mui-error {
color: #f44336;
}
.MuiFormLabel-colorSecondary.Mui-focused {
color: #0077C0;
}
.MuiFormLabel-asterisk.Mui-error {
color: #f44336;
}
</style>
<style data-jss="" data-meta="MuiGrid">
.MuiGrid-container {
width: 100%;
display: flex;
flex-wrap: wrap;
box-sizing: border-box;
}
.MuiGrid-item {
margin: 0;
box-sizing: border-box;
}
.MuiGrid-zeroMinWidth {
min-width: 0;
}
.MuiGrid-direction-xs-column {
flex-direction: column;
}
.MuiGrid-direction-xs-column-reverse {
flex-direction: column-reverse;
}
.MuiGrid-direction-xs-row-reverse {
flex-direction: row-reverse;
}
.MuiGrid-wrap-xs-nowrap {
flex-wrap: nowrap;
}
.MuiGrid-wrap-xs-wrap-reverse {
flex-wrap: wrap-reverse;
}
.MuiGrid-align-items-xs-center {
align-items: center;
}
.MuiGrid-align-items-xs-flex-start {
align-items: flex-start;
}
.MuiGrid-align-items-xs-flex-end {
align-items: flex-end;
}
.MuiGrid-align-items-xs-baseline {
align-items: baseline;
}
.MuiGrid-align-content-xs-center {
align-content: center;
}
.MuiGrid-align-content-xs-flex-start {
align-content: flex-start;
}
.MuiGrid-align-content-xs-flex-end {
align-content: flex-end;
}
.MuiGrid-align-content-xs-space-between {
align-content: space-between;
}
.MuiGrid-align-content-xs-space-around {
align-content: space-around;
}
.MuiGrid-justify-content-xs-center {
justify-content: center;
}
.MuiGrid-justify-content-xs-flex-end {
justify-content: flex-end;
}
.MuiGrid-justify-content-xs-space-between {
justify-content: space-between;
}
.MuiGrid-justify-content-xs-space-around {
justify-content: space-around;
}
.MuiGrid-justify-content-xs-space-evenly {
justify-content: space-evenly;
}
.MuiGrid-spacing-xs-1 {
width: calc(100% + 8px);
margin: -4px;
}
.MuiGrid-spacing-xs-1>.MuiGrid-item {
padding: 4px;
}
.MuiGrid-spacing-xs-2 {
width: calc(100% + 16px);
margin: -8px;
}
.MuiGrid-spacing-xs-2>.MuiGrid-item {
padding: 8px;
}
.MuiGrid-spacing-xs-3 {
width: calc(100% + 24px);
margin: -12px;
}
.MuiGrid-spacing-xs-3>.MuiGrid-item {
padding: 12px;
}
.MuiGrid-spacing-xs-4 {
width: calc(100% + 32px);
margin: -16px;
}
.MuiGrid-spacing-xs-4>.MuiGrid-item {
padding: 16px;
}
.MuiGrid-spacing-xs-5 {
width: calc(100% + 40px);
margin: -20px;
}
.MuiGrid-spacing-xs-5>.MuiGrid-item {
padding: 20px;
}
.MuiGrid-spacing-xs-6 {
width: calc(100% + 48px);
margin: -24px;
}
.MuiGrid-spacing-xs-6>.MuiGrid-item {
padding: 24px;
}
.MuiGrid-spacing-xs-7 {
width: calc(100% + 56px);
margin: -28px;
}
.MuiGrid-spacing-xs-7>.MuiGrid-item {
padding: 28px;
}
.MuiGrid-spacing-xs-8 {
width: calc(100% + 64px);
margin: -32px;
}
.MuiGrid-spacing-xs-8>.MuiGrid-item {
padding: 32px;
}
.MuiGrid-spacing-xs-9 {
width: calc(100% + 72px);
margin: -36px;
}
.MuiGrid-spacing-xs-9>.MuiGrid-item {
padding: 36px;
}
.MuiGrid-spacing-xs-10 {
width: calc(100% + 80px);
margin: -40px;
}
.MuiGrid-spacing-xs-10>.MuiGrid-item {
padding: 40px;
}
.MuiGrid-grid-xs-auto {
flex-grow: 0;
max-width: none;
flex-basis: auto;
}
.MuiGrid-grid-xs-true {
flex-grow: 1;
max-width: 100%;
flex-basis: 0;
}
.MuiGrid-grid-xs-1 {
flex-grow: 0;
max-width: 8.333333%;
flex-basis: 8.333333%;
}
.MuiGrid-grid-xs-2 {
flex-grow: 0;
max-width: 16.666667%;
flex-basis: 16.666667%;
}
.MuiGrid-grid-xs-3 {
flex-grow: 0;
max-width: 25%;
flex-basis: 25%;
}
.MuiGrid-grid-xs-4 {
flex-grow: 0;
max-width: 33.333333%;
flex-basis: 33.333333%;
}
.MuiGrid-grid-xs-5 {
flex-grow: 0;
max-width: 41.666667%;
flex-basis: 41.666667%;
}
.MuiGrid-grid-xs-6 {
flex-grow: 0;
max-width: 50%;
flex-basis: 50%;
}
.MuiGrid-grid-xs-7 {
flex-grow: 0;
max-width: 58.333333%;
flex-basis: 58.333333%;
}
.MuiGrid-grid-xs-8 {
flex-grow: 0;
max-width: 66.666667%;
flex-basis: 66.666667%;
}
.MuiGrid-grid-xs-9 {
flex-grow: 0;
max-width: 75%;
flex-basis: 75%;
}
.MuiGrid-grid-xs-10 {
flex-grow: 0;
max-width: 83.333333%;
flex-basis: 83.333333%;
}
.MuiGrid-grid-xs-11 {
flex-grow: 0;
max-width: 91.666667%;
flex-basis: 91.666667%;
}
.MuiGrid-grid-xs-12 {
flex-grow: 0;
max-width: 100%;
flex-basis: 100%;
}
@media (min-width:600px) {
.MuiGrid-grid-sm-auto {
flex-grow: 0;
max-width: none;
flex-basis: auto;
}
.MuiGrid-grid-sm-true {
flex-grow: 1;
max-width: 100%;
flex-basis: 0;
}
.MuiGrid-grid-sm-1 {
flex-grow: 0;
max-width: 8.333333%;
flex-basis: 8.333333%;
}
.MuiGrid-grid-sm-2 {
flex-grow: 0;
max-width: 16.666667%;
flex-basis: 16.666667%;
}
.MuiGrid-grid-sm-3 {
flex-grow: 0;
max-width: 25%;
flex-basis: 25%;
}
.MuiGrid-grid-sm-4 {
flex-grow: 0;
max-width: 33.333333%;
flex-basis: 33.333333%;
}
.MuiGrid-grid-sm-5 {
flex-grow: 0;
max-width: 41.666667%;
flex-basis: 41.666667%;
}
.MuiGrid-grid-sm-6 {
flex-grow: 0;
max-width: 50%;
flex-basis: 50%;
}
.MuiGrid-grid-sm-7 {
flex-grow: 0;
max-width: 58.333333%;
flex-basis: 58.333333%;
}
.MuiGrid-grid-sm-8 {
flex-grow: 0;
max-width: 66.666667%;
flex-basis: 66.666667%;
}
.MuiGrid-grid-sm-9 {
flex-grow: 0;
max-width: 75%;
flex-basis: 75%;
}
.MuiGrid-grid-sm-10 {
flex-grow: 0;
max-width: 83.333333%;
flex-basis: 83.333333%;
}
.MuiGrid-grid-sm-11 {
flex-grow: 0;
max-width: 91.666667%;
flex-basis: 91.666667%;
}
.MuiGrid-grid-sm-12 {
flex-grow: 0;
max-width: 100%;
flex-basis: 100%;
}
}
@media (min-width:960px) {
.MuiGrid-grid-md-auto {
flex-grow: 0;
max-width: none;
flex-basis: auto;
}
.MuiGrid-grid-md-true {
flex-grow: 1;
max-width: 100%;
flex-basis: 0;
}
.MuiGrid-grid-md-1 {
flex-grow: 0;
max-width: 8.333333%;
flex-basis: 8.333333%;
}
.MuiGrid-grid-md-2 {
flex-grow: 0;
max-width: 16.666667%;
flex-basis: 16.666667%;
}
.MuiGrid-grid-md-3 {
flex-grow: 0;
max-width: 25%;
flex-basis: 25%;
}
.MuiGrid-grid-md-4 {
flex-grow: 0;
max-width: 33.333333%;
flex-basis: 33.333333%;
}
.MuiGrid-grid-md-5 {
flex-grow: 0;
max-width: 41.666667%;
flex-basis: 41.666667%;
}
.MuiGrid-grid-md-6 {
flex-grow: 0;
max-width: 50%;
flex-basis: 50%;
}
.MuiGrid-grid-md-7 {
flex-grow: 0;
max-width: 58.333333%;
flex-basis: 58.333333%;
}
.MuiGrid-grid-md-8 {
flex-grow: 0;
max-width: 66.666667%;
flex-basis: 66.666667%;
}
.MuiGrid-grid-md-9 {
flex-grow: 0;
max-width: 75%;
flex-basis: 75%;
}
.MuiGrid-grid-md-10 {
flex-grow: 0;
max-width: 83.333333%;
flex-basis: 83.333333%;
}
.MuiGrid-grid-md-11 {
flex-grow: 0;
max-width: 91.666667%;
flex-basis: 91.666667%;
}
.MuiGrid-grid-md-12 {
flex-grow: 0;
max-width: 100%;
flex-basis: 100%;
}
}
@media (min-width:1280px) {
.MuiGrid-grid-lg-auto {
flex-grow: 0;
max-width: none;
flex-basis: auto;
}
.MuiGrid-grid-lg-true {
flex-grow: 1;
max-width: 100%;
flex-basis: 0;
}
.MuiGrid-grid-lg-1 {
flex-grow: 0;
max-width: 8.333333%;
flex-basis: 8.333333%;
}
.MuiGrid-grid-lg-2 {
flex-grow: 0;
max-width: 16.666667%;
flex-basis: 16.666667%;
}
.MuiGrid-grid-lg-3 {
flex-grow: 0;
max-width: 25%;
flex-basis: 25%;
}
.MuiGrid-grid-lg-4 {
flex-grow: 0;
max-width: 33.333333%;
flex-basis: 33.333333%;
}
.MuiGrid-grid-lg-5 {
flex-grow: 0;
max-width: 41.666667%;
flex-basis: 41.666667%;
}
.MuiGrid-grid-lg-6 {
flex-grow: 0;
max-width: 50%;
flex-basis: 50%;
}
.MuiGrid-grid-lg-7 {
flex-grow: 0;
max-width: 58.333333%;
flex-basis: 58.333333%;
}
.MuiGrid-grid-lg-8 {
flex-grow: 0;
max-width: 66.666667%;
flex-basis: 66.666667%;
}
.MuiGrid-grid-lg-9 {
flex-grow: 0;
max-width: 75%;
flex-basis: 75%;
}
.MuiGrid-grid-lg-10 {
flex-grow: 0;
max-width: 83.333333%;
flex-basis: 83.333333%;
}
.MuiGrid-grid-lg-11 {
flex-grow: 0;
max-width: 91.666667%;
flex-basis: 91.666667%;
}
.MuiGrid-grid-lg-12 {
flex-grow: 0;
max-width: 100%;
flex-basis: 100%;
}
}
@media (min-width:1920px) {
.MuiGrid-grid-xl-auto {
flex-grow: 0;
max-width: none;
flex-basis: auto;
}
.MuiGrid-grid-xl-true {
flex-grow: 1;
max-width: 100%;
flex-basis: 0;
}
.MuiGrid-grid-xl-1 {
flex-grow: 0;
max-width: 8.333333%;
flex-basis: 8.333333%;
}
.MuiGrid-grid-xl-2 {
flex-grow: 0;
max-width: 16.666667%;
flex-basis: 16.666667%;
}
.MuiGrid-grid-xl-3 {
flex-grow: 0;
max-width: 25%;
flex-basis: 25%;
}
.MuiGrid-grid-xl-4 {
flex-grow: 0;
max-width: 33.333333%;
flex-basis: 33.333333%;
}
.MuiGrid-grid-xl-5 {
flex-grow: 0;
max-width: 41.666667%;
flex-basis: 41.666667%;
}
.MuiGrid-grid-xl-6 {
flex-grow: 0;
max-width: 50%;
flex-basis: 50%;
}
.MuiGrid-grid-xl-7 {
flex-grow: 0;
max-width: 58.333333%;
flex-basis: 58.333333%;
}
.MuiGrid-grid-xl-8 {
flex-grow: 0;
max-width: 66.666667%;
flex-basis: 66.666667%;
}
.MuiGrid-grid-xl-9 {
flex-grow: 0;
max-width: 75%;
flex-basis: 75%;
}
.MuiGrid-grid-xl-10 {
flex-grow: 0;
max-width: 83.333333%;
flex-basis: 83.333333%;
}
.MuiGrid-grid-xl-11 {
flex-grow: 0;
max-width: 91.666667%;
flex-basis: 91.666667%;
}
.MuiGrid-grid-xl-12 {
flex-grow: 0;
max-width: 100%;
flex-basis: 100%;
}
}
</style>
<style data-jss="" data-meta="MuiInput">
.MuiInput-root {
position: relative;
}
label+.MuiInput-formControl {
margin-top: 16px;
}
.MuiInput-colorSecondary.MuiInput-underline:after {
border-bottom-color: #0077C0;
}
.MuiInput-underline:after {
left: 0;
right: 0;
bottom: 0;
content: "";
position: absolute;
transform: scaleX(0);
transition: transform 200ms cubic-bezier(0.0, 0, 0.2, 1) 0ms;
border-bottom: 2px solid #54b847;
pointer-events: none;
}
.MuiInput-underline.Mui-focused:after {
transform: scaleX(1);
}
.MuiInput-underline.Mui-error:after {
transform: scaleX(1);
border-bottom-color: #f44336;
}
.MuiInput-underline:before {
left: 0;
right: 0;
bottom: 0;
content: "\00a0";
position: absolute;
transition: border-bottom-color 200ms cubic-bezier(0.4, 0, 0.2, 1) 0ms;
border-bottom: 1px solid rgba(0, 0, 0, 0.42);
pointer-events: none;
}
.MuiInput-underline:hover:not(.Mui-disabled):before {
border-bottom: 2px solid rgba(0, 0, 0, 0.87);
}
.MuiInput-underline.Mui-disabled:before {
border-bottom-style: dotted;
}
@media (hover: none) {
.MuiInput-underline:hover:not(.Mui-disabled):before {
border-bottom: 1px solid rgba(0, 0, 0, 0.42);
}
}
</style>
<style data-jss="" data-meta="MuiInputAdornment">
.MuiInputAdornment-root {
height: 0.01em;
display: flex;
max-height: 2em;
align-items: center;
white-space: nowrap;
}
.MuiInputAdornment-filled.MuiInputAdornment-positionStart:not(.MuiInputAdornment-hiddenLabel) {
margin-top: 16px;
}
.MuiInputAdornment-positionStart {
margin-right: 8px;
}
.MuiInputAdornment-positionEnd {
margin-left: 8px;
}
.MuiInputAdornment-disablePointerEvents {
pointer-events: none;
}
</style>
<style data-jss="" data-meta="MuiInputLabel">
.MuiInputLabel-root {
display: block;
transform-origin: top left;
}
.MuiInputLabel-formControl {
top: 0;
left: 0;
position: absolute;
transform: translate(0, 24px) scale(1);
}
.MuiInputLabel-marginDense {
transform: translate(0, 21px) scale(1);
}
.MuiInputLabel-shrink {
transform: translate(0, 1.5px) scale(0.75);
transform-origin: top left;
}
.MuiInputLabel-animated {
transition: color 200ms cubic-bezier(0.0, 0, 0.2, 1) 0ms, transform 200ms cubic-bezier(0.0, 0, 0.2, 1) 0ms;
}
.MuiInputLabel-filled {
z-index: 1;
transform: translate(12px, 20px) scale(1);
pointer-events: none;
}
.MuiInputLabel-filled.MuiInputLabel-marginDense {
transform: translate(12px, 17px) scale(1);
}
.MuiInputLabel-filled.MuiInputLabel-shrink {
transform: translate(12px, 10px) scale(0.75);
}
.MuiInputLabel-filled.MuiInputLabel-shrink.MuiInputLabel-marginDense {
transform: translate(12px, 7px) scale(0.75);
}
.MuiInputLabel-outlined {
z-index: 1;
transform: translate(14px, 20px) scale(1);
pointer-events: none;
}
.MuiInputLabel-outlined.MuiInputLabel-marginDense {
transform: translate(14px, 12px) scale(1);
}
.MuiInputLabel-outlined.MuiInputLabel-shrink {
transform: translate(14px, -6px) scale(0.75);
margin-top: -4px;
background: #fff;
}
</style>
<style data-jss="" data-meta="PrivateNotchedOutline">
.PrivateNotchedOutline-root-45 {
top: -5px;
left: 0;
right: 0;
bottom: 0;
margin: 0;
padding: 0 8px;
overflow: hidden;
position: absolute;
border-style: solid;
border-width: 1px;
border-radius: inherit;
pointer-events: none;
}
.PrivateNotchedOutline-legend-46 {
padding: 0;
text-align: left;
transition: width 150ms cubic-bezier(0.0, 0, 0.2, 1) 0ms;
line-height: 11px;
}
.PrivateNotchedOutline-legendLabelled-47 {
width: auto;
height: 11px;
display: block;
padding: 0;
font-size: 0.75em;
max-width: 0.01px;
text-align: left;
transition: max-width 50ms cubic-bezier(0.0, 0, 0.2, 1) 0ms;
visibility: hidden;
}
.PrivateNotchedOutline-legendLabelled-47>span {
display: inline-block;
padding-left: 5px;
padding-right: 5px;
}
.PrivateNotchedOutline-legendNotched-48 {
max-width: 1000px;
transition: max-width 100ms cubic-bezier(0.0, 0, 0.2, 1) 50ms;
}
</style>
<style data-jss="" data-meta="MuiOutlinedInput">
.MuiOutlinedInput-root {
position: relative;
border-radius: 4px;
}
.MuiOutlinedInput-root:hover .MuiOutlinedInput-notchedOutline {
border-color: rgba(0, 0, 0, 0.87);
}
@media (hover: none) {
.MuiOutlinedInput-root:hover .MuiOutlinedInput-notchedOutline {
border-color: rgba(0, 0, 0, 0.23);
}
}
.MuiOutlinedInput-root.Mui-focused .MuiOutlinedInput-notchedOutline {
border-color: #54b847;
border-width: 2px;
}
.MuiOutlinedInput-root.Mui-error .MuiOutlinedInput-notchedOutline {
border-color: #f44336;
}
.MuiOutlinedInput-root.Mui-disabled .MuiOutlinedInput-notchedOutline {
border-color: rgba(0, 0, 0, 0.26);
}
.MuiOutlinedInput-colorSecondary.Mui-focused .MuiOutlinedInput-notchedOutline {
border-color: #0077C0;
}
.MuiOutlinedInput-adornedStart {
padding-left: 14px;
}
.MuiOutlinedInput-adornedEnd {
padding-right: 14px;
}
.MuiOutlinedInput-multiline {
padding: 18.5px 14px;
}
.MuiOutlinedInput-multiline.MuiOutlinedInput-marginDense {
padding-top: 10.5px;
padding-bottom: 10.5px;
}
.MuiOutlinedInput-notchedOutline {
border-color: rgba(0, 0, 0, 0.23);
}
.MuiOutlinedInput-input {
padding: 18.5px 14px;
}
.MuiOutlinedInput-input:-webkit-autofill {
border-radius: inherit;
}
.MuiOutlinedInput-inputMarginDense {
padding-top: 10.5px;
padding-bottom: 10.5px;
}
.MuiOutlinedInput-inputMultiline {
padding: 0;
}
.MuiOutlinedInput-inputAdornedStart {
padding-left: 0;
}
.MuiOutlinedInput-inputAdornedEnd {
padding-right: 0;
}
</style>
<style data-jss="" data-meta="MuiSelect">
.MuiSelect-select {
cursor: pointer;
min-width: 16px;
user-select: none;
border-radius: 0;
-moz-appearance: none;
-webkit-appearance: none;
}
.MuiSelect-select:focus {
border-radius: 0;
background-color: rgba(0, 0, 0, 0.05);
}
.MuiSelect-select::-ms-expand {
display: none;
}
.MuiSelect-select.Mui-disabled {
cursor: default;
}
.MuiSelect-select[multiple] {
height: auto;
}
.MuiSelect-select:not([multiple]) option,
.MuiSelect-select:not([multiple]) optgroup {
background-color: #fff;
}
.MuiSelect-select.MuiSelect-select {
padding-right: 24px;
}
.MuiSelect-filled.MuiSelect-filled {
padding-right: 32px;
}
.MuiSelect-outlined {
border-radius: 4px;
}
.MuiSelect-outlined.MuiSelect-outlined {
padding-right: 32px;
}
.MuiSelect-selectMenu {
height: auto;
overflow: hidden;
min-height: 1.1876em;
white-space: nowrap;
text-overflow: ellipsis;
}
.MuiSelect-icon {
top: calc(50% - 12px);
color: rgba(0, 0, 0, 0.54);
right: 0;
position: absolute;
pointer-events: none;
}
.MuiSelect-icon.Mui-disabled {
color: rgba(0, 0, 0, 0.26);
}
.MuiSelect-iconOpen {
transform: rotate(180deg);
}
.MuiSelect-iconFilled {
right: 7px;
}
.MuiSelect-iconOutlined {
right: 7px;
}
.MuiSelect-nativeInput {
left: 0;
width: 100%;
bottom: 0;
opacity: 0;
position: absolute;
pointer-events: none;
}
</style>
<style data-jss="" data-meta="MuiTextField">
</style>
<style data-jss="" data-meta="makeStyles">
.makeStyles-root-29 {
width: 100%;
}
/* .makeStyles-textField-30 {
width: 280px;
height: 40px;
} */
@media (max-width:959.95px) {
.makeStyles-textField-30 {
width: 100%;
}
}
.makeStyles-spacerExtraLarge-31 {
margin-bottom: 64px;
}
.makeStyles-spacerLarge-32 {
margin-bottom: 48px;
}
.makeStyles-spacer-33 {
margin-bottom: 32px;
}
.makeStyles-spacerMedium-34 {
margin-bottom: 24px;
}
.makeStyles-spacerSmall-35 {
margin-bottom: 16px;
}
.makeStyles-spacerExtraSmall-36 {
margin-bottom: 8px;
}
.makeStyles-paperRoot-37 {
display: flex;
padding: 24px 22px;
flex-flow: column nowrap;
border-radius: 5px;
background-color: transparent;
}
.makeStyles-fieldSet-38 {
flex-wrap: nowrap;
flex-direction: row;
}
.makeStyles-genderRadio-39 {
color: #1399e8 !important;
}
.makeStyles-caption-40 {
font-size: 14px;
font-weight: 600;
}
.makeStyles-menuItem-41:hover {
background-color: #1399e8 !important;
}
.makeStyles-formControlSelect-42 {
height: auto;
top: -8px;
}
.makeStyles-gridContainer-43 {
display: flex;
flex-wrap: nowrap;
flex-direction: row;
justify-content: space-between;
}
@media (max-width:959.95px) {
.makeStyles-gridContainer-43 {
flex-direction: column;
justify-content: none;
}
}
/* .makeStyles-gridItem-44 {
margin-right: 15px;
} */
@media (max-width:959.95px) {
.makeStyles-gridItem-44 {
margin-bottom: 16px;
}
}
</style>
<style data-jss="" data-meta="makeStyles">
/* .makeStyles-formControl-53 label.MuiFormLabel-root {
top: -9px;
}*/
.makeStyles-spacer-54 {
margin-bottom: 32px;
}
.makeStyles-spacerMedium-55 {
margin-bottom: 24px;
}
.makeStyles-spacerSmall-56 {
margin-bottom: 16px;
}
.makeStyles-textFieldRoot-57 {
width: 566px;
height: 40px;
}
.makeStyles-paperRoot-58 {
display: flex;
flex-flow: column nowrap;
border-radius: 5px;
background-color: transparent;
flex-direction: row;
align-items: center;
justify-content: space-between;
padding: 0 10px;
}
.makeStyles-caption-59 {
font-size: 14px;
font-weight: 600;
line-height: 19px;
}
.makeStyles-selectMenuItem-60:hover {
background-color: #0077C0 !important;
}
.makeStyles-paperItem-61 {
display: flex;
/* padding: 24px 22px; */
flex-flow: row wrap;
border-radius: 5px;
justify-content: space-between;
padding: 0 10px;
background-color: transparent;
}
.makeStyles-paperItem-61-2 {
display: flex;
padding: 0 10px;
}
.makeStyles-textField-62 {
width: 280px;
height: 40px;
margin-top: 10px;
}
@media (max-width:959.95px) {
.makeStyles-textField-62 {
width: 100%;
}
}
.makeStyles-formControlWeight-63 {
display: flex;
margin-bottom: 32px;
flex-direction: row;
}
.makeStyles-formControlSerum-64 {
display: flex;
margin-bottom: 32px;
flex-direction: row;
}
.makeStyles-margin-66 {
margin: 0 8px;
}
</style>
<style data-jss="" data-meta="makeStyles">
.makeStyles-root-67 {
width: 100%;
}
.makeStyles-textField-68 {
width: 280px;
height: 40px;
}
@media (max-width:959.95px) {
.makeStyles-textField-68 {
width: 100%;
}
}
.makeStyles-spacerExtraLarge-69 {
margin-bottom: 64px;
}
.makeStyles-spacerLarge-70 {
margin-bottom: 48px;
}
.makeStyles-spacer-71 {
margin-bottom: 32px;
}
.makeStyles-spacerMedium-72 {
margin-bottom: 24px;
}
.makeStyles-spacerSmall-73 {
margin-bottom: 16px;
}
.makeStyles-spacerExtraSmall-74 {
margin-bottom: 8px;
}
.makeStyles-paperRoot-75 {
display: flex;
padding: 15px 22px;
flex-flow: column nowrap;
flex-basis: 50%;
background-color: transparent;
}
.makeStyles-fieldSet-76 {
flex-wrap: nowrap;
flex-direction: row;
}
.makeStyles-caption-77 {
font-size: 14px;
font-weight: 600;
}
.makeStyles-formControlSelect-78 {
padding: 12px 5px;
}
.makeStyles-gridContainer-79 {
display: flex;
flex-wrap: nowrap;
flex-direction: row;
}
@media (max-width:959.95px) {
.makeStyles-gridContainer-79 {
flex-direction: column;
justify-content: none;
}
}
.makeStyles-gridItem-80 {
padding: 5px;
}
@media (max-width:959.95px) {
.makeStyles-gridItem-80 {
margin-bottom: 16px;
}
}
.makeStyles-title-81 {
font-size: 16px;
font-weight: 600;
}
.makeStyles-items-82 {
margin: 5px;
padding: 5px;
}
.makeStyles-itemContents-83 {
display: grid;
grid-template-columns: 1fr 1fr;
}
.makeStyles-formControl-84 {
padding: 5px 10px;
}
.makeStyles-formLabel-85 {
color: #000;
}
</style>
<style data-jss="" data-meta="makeStyles">
.makeStyles-root-86 {
width: 100%;
}
.makeStyles-textField-87 {
width: 280px;
height: 40px;
}
@media (max-width:959.95px) {
.makeStyles-textField-87 {
width: 100%;
}
}
.makeStyles-spacerExtraLarge-88 {
margin-bottom: 64px;
}
.makeStyles-spacerLarge-89 {
margin-bottom: 48px;
}
.makeStyles-spacer-90 {
margin-bottom: 32px;
}
.makeStyles-spacerMedium-91 {
margin-bottom: 24px;
}
.makeStyles-spacerSmall-92 {
margin-bottom: 16px;
}
.makeStyles-spacerExtraSmall-93 {
margin-bottom: 8px;
}
.makeStyles-paperRoot-94 {
display: flex;
padding: 24px 22px;
flex-flow: column nowrap;
border-radius: 5px;
background-color: transparent;
}
.makeStyles-paperRootInfo-95 {
height: 250px;
margin: 0 auto;
padding: 16px 24px;
max-width: 80% !important;
overflow-y: scroll;
background-color: transparent;
}
.makeStyles-fieldSet-96 {
flex-wrap: nowrap;
flex-direction: row;
}
.makeStyles-genderRadio-97 {
color: #1399e8 !important;
}
.makeStyles-caption-98 {
font-size: 14px;
font-weight: 600;
}
.makeStyles-menuItem-99:hover {
background-color: #1399e8 !important;
}
.makeStyles-formControlSelect-100 {
padding: 12px 5px;
}
.makeStyles-gridContainer-101 {
display: flex;
flex-wrap: nowrap;
flex-direction: row;
justify-content: space-between;
}
@media (max-width:959.95px) {
.makeStyles-gridContainer-101 {
flex-direction: column;
justify-content: none;
}
}
/* .makeStyles-gridItem-102 {
margin-right: 15px;
}*/
@media (max-width:959.95px) {
.makeStyles-gridItem-102 {
margin-bottom: 16px;
}
}
@media (max-width:959.95px) {
.makeStyles-searchContainer-103 {
justify-content: center;
}
}
.makeStyles-paperSearch-104 {
background-color: transparent;
padding: 0px 22px;
}
@media (max-width:959.95px) {
.makeStyles-paperSearch-104 {
margin-left: 0;
}
}
.makeStyles-searchField-105 {
width: 280px;
height: 40px;
/*margin-left: 13px; */
}
.makeStyles-signPadRoot-106 {
padding: 0 22px;
margin-right: 0;
float: left;
width: auto;
margin-top: 20px;
}
@media (max-width:959.95px) {
.makeStyles-signPadRoot-106 {
padding: 12px 6px;
}
}
.makeStyles-signPadPlaceHolder-107 {
width: 280px;
cursor: pointer;
height: 77px;
display: flex;
background: #FDE0E0 0% 0% no-repeat padding-box;
align-items: center;
border-radius: 4px;
justify-content: center;
}
.makeStyles-cosentCotainer-108 {
align-items: center;
justify-content: space-between;
justify-content: baseline;
}
</style>
<style data-jss="" data-meta="makeStyles">
.makeStyles-root-123 {
width: 100%;
}
.makeStyles-textField-124 {
width: 280px;
height: 40px;
}
@media (max-width:959.95px) {
.makeStyles-textField-124 {
width: 100%;
}
}
.makeStyles-spacerExtraLarge-125 {
margin-bottom: 64px;
}
.makeStyles-spacerLarge-126 {
margin-bottom: 48px;
}
.makeStyles-spacer-127 {
margin-bottom: 32px;
}
.makeStyles-spacerMedium-128 {
margin-bottom: 24px;
}
.makeStyles-spacerSmall-129 {
margin-bottom: 16px;
}
.makeStyles-spacerExtraSmall-130 {
margin-bottom: 8px;
}
.makeStyles-paperRoot-131 {
display: flex;
padding: 24px 22px;
flex-flow: column nowrap;
border-radius: 5px;
background-color: transparent;
}
.makeStyles-paperRootInfo-132 {
margin: 0 auto;
padding: 16px 24px;
background-color: transparent;
}
.makeStyles-paperRootInfo-132-1 {
padding: 16px 24px;
background-color: transparent;
}
.makeStyles-fieldSet-133 {
flex-wrap: nowrap;
flex-direction: row;
}
.makeStyles-caption-134 {
font-size: 14px;
font-weight: 600;
}
.makeStyles-gridContainer-135 {
display: flex;
flex-wrap: nowrap;
flex-direction: row;
}
@media (max-width:959.95px) {
.makeStyles-gridContainer-135 {
flex-direction: column;
justify-content: none;
}
}
.makeStyles-gridItem-136 {
margin-right: 15px;
}
@media (max-width:959.95px) {
.makeStyles-gridItem-136 {
margin-bottom: 16px;
}
}
</style>
<style data-jss="" data-meta="makeStyles">
.makeStyles-root-109 {
width: 100%;
}
.makeStyles-textField-110 {
width: 749px;
height: 40px;
}
@media (max-width:959.95px) {
.makeStyles-textField-110 {
width: 100%;
}
}
.makeStyles-spacerExtraLarge-111 {
margin-bottom: 64px;
}
.makeStyles-spacerLarge-112 {
margin-bottom: 48px;
}
.makeStyles-spacer-113 {
margin-bottom: 32px;
}
.makeStyles-spacerMedium-114 {
margin-bottom: 24px;
}
.makeStyles-spacerSmall-115 {
margin-bottom: 16px;
}
.makeStyles-spacerExtraSmall-116 {
margin-bottom: 8px;
}
.makeStyles-paperRoot-117 {
display: flex;
padding: 24px 22px;
flex-flow: column nowrap;
border-radius: 5px;
background-color: transparent;
}
.makeStyles-paperRootInfo-118 {
padding: 0 16px;
background-color: transparent;
}
.makeStyles-fieldSet-119 {
flex-wrap: nowrap;
flex-direction: row;
}
.makeStyles-caption-120 {
font-size: 14px;
font-weight: 600;
}
.makeStyles-gridContainer-121 {
display: flex;
flex-wrap: nowrap;
flex-direction: row;
}
@media (max-width:959.95px) {
.makeStyles-gridContainer-121 {
flex-direction: column;
justify-content: none;
}
}
.makeStyles-gridItem-122 {
margin-right: 15px;
}
@media (max-width:959.95px) {
.makeStyles-gridItem-122 {
margin-bottom: 16px;
}
}
</style>
<style data-jss="" data-meta="makeStyles">
.makeStyles-spacerExtraLarge-15 {
margin-bottom: 64px;
}
.makeStyles-spacerLarge-16 {
margin-bottom: 48px;
}
.makeStyles-spacer-17 {
margin-bottom: 32px;
}
.makeStyles-spacerMedium-18 {
margin-bottom: 24px;
}
.makeStyles-spacerSmall-19 {
margin-bottom: 16px;
}
.makeStyles-spacerExtraSmall-20 {
margin-bottom: 8px;
}
.makeStyles-root-21 {
width: 100%;
}
.makeStyles-heading-22 {
color: #54b847;
font-size: 1.25rem;
flex-shrink: 0;
font-weight: bold;
}
.makeStyles-secondaryHeading-23 {
color: rgba(0, 0, 0, 0.54);
font-size: 0.9375rem;
}
.makeStyles-accordionRoot-24 {
background: #FAFAFA;
box-shadow: 0px 2px 6px #54b847;
border-radius: 12px;
}
.makeStyles-accordionRoot-24:before {
height: 0;
}
.makeStyles-accordionRoot-24:first-child {
border-radius: 12px;
}
.makeStyles-accordionRoot-24:last-child {
border-radius: 12px;
}
.makeStyles-accordionSummaryRoot-25 {
padding: 28px 16px;
margin-bottom: 0 !important;
justify-content: flex-start;
}
.makeStyles-accordionSummaryExpanded-26 {
border-radius: 12px;
background-color: #FAFAFA !important;
}
.makeStyles-accordionSummaryExpandedIcon-27 {
color: #fff;
width: 24px;
height: 24px;
border-radius: 50%;
background-color: #54b847;
}
.makeStyles-accordionSummaryContent-28 {
flex-grow: 0;
}
@media (max-width:959.95px) {
.makeStyles-accordionSummaryContent-28 {
display: block;
}
}
</style>
<style data-jss="" data-meta="makeStyles">
.makeStyles-container-1 {
width: 100%;
background: #fff;
}
.makeStyles-spacerExtraLarge-2 {
margin-bottom: 64px;
}
.makeStyles-spacerLarge-3 {
margin-bottom: 48px;
}
.makeStyles-spacer-4 {
margin-bottom: 32px;
}
.makeStyles-spacerMedium-5 {
margin-bottom: 24px;
}
.makeStyles-spacerSmall-6 {
margin-bottom: 16px;
}
.makeStyles-spacerExtraSmall-7 {
margin-bottom: 8px;
}
.makeStyles-root-8 {
margin: 0 auto;
padding: 16px 0;
max-width: calc(100% - 354px);
}
@media (max-width:959.95px) {
.makeStyles-root-8 {
width: 100%;
padding: 16px 24px;
max-width: none;
}
}
.makeStyles-submitButton-9 {
display: flex;
}
@media (max-width:959.95px) {
.makeStyles-submitButton-9 {
display: flex;
}
}
.makeStyles-caption-10 {
color: #000;
font-size: 16px;
font-weight: 600;
padding-left: 12px;
}
.makeStyles-pageTitle-11 {
color: #0077C0;
display: flex;
font-size: 22px;
font-weight: 600;
justify-content: center;
}
@media (max-width:959.95px) {
.makeStyles-pageTitle-11 {
font-size: 15px;
}
}
.makeStyles-logoContainer-12 {
width: 90%;
margin: 0 auto;
display: flex;
padding-top: 25px;
justify-content: space-between;
}
.makeStyles-everSanaLogo-13 {
margin-right: 70px;
padding-right: 34px;
}
.makeStyles-prolastinLogo-14 {
padding: 10px;
}
</style>
<style data-styled="active" data-styled-version="5.2.1">
.hjcAQm {
background-color: #54b847;
border: none;
border-radius: 3px;
color: #fff;
padding: 9px;
font-weight: 300;
margin-left: 25px;
}
.gbmIEA {
color: #fff;
background: #54b847 0% 0% no-repeat padding-box;
border-radius: 5px;
top: 5245px;
left: 857px;
width: 207px;
height: 57px;
border: none;
font-size: 16px;
margin: auto;
}
.height-40 {
height: 40px;
}
</style>
<style>
.weightUnitsLabel{
top: 0 !important;
left: 0 !important;
font-size: inherit !important;
background: transparent !important;
padding: 0 !important;
}
.fevi_label{
top: -9px;
}
.hours_of_op{
padding: 0 22px;
}
.signing_text{
padding: 0 22px;
}
@media screen and (max-width: 580px) {
.best_time {
display: block;
}
.best_time label{
width: 100%;
float: left;
}
.makeStyles-paperRoot-58{
display: block;
padding: 0;
}
.makeStyles-paperItem-61 {
display: block;
padding: 0;
}
.makeStyles-paperItem-61-2 {
display: block;
padding: 0;
}
.MuiFormGroup-root.allergies_group{
display: block;
}
.makeStyles-itemContents-83 {
display: block;
}
.makeStyles-paperRoot-94{
padding: 0;
}
.checklist_block button{
margin: 0;
margin-bottom: 10px;
}
.makeStyles-paperRootInfo-132{
padding: 16px 10px;
}
.copyright_footer span{
width: 100%;
float: left;
}
.makeStyles-paperRoot-37 {
padding: 24px 0;
}
.makeStyles-formControlSerum-64, .makeStyles-formControlWeight-63 {
display: block;
}
.signing_text{
padding: 0;
}
}
</style>
</head>
<body id="kt_body"
class="quick-panel-right demo-panel-right offcanvas-right header-fixed header-mobile-fixed aside-enabled aside-fixed aside-minimize-hoverable brand-light"
style=""><noscript>Eversana Platform needs JavaScript to run.</noscript>
<div id="root">
<div class="makeStyles-container-1">
<div class="MuiGrid-root makeStyles-logoContainer-12 MuiGrid-container">
<div class="MuiGrid-root MuiGrid-item"><img
src="https://www.stg.rxcurie.com/media/prolastin/prolastinDirect_logo.PNG" alt="prolastinDirect"></div>
<div class="MuiGrid-root makeStyles-everSanaLogo-13 MuiGrid-item"><img
src="https://www.stg.rxcurie.com/media/prolastin/eversana_logo.PNG" alt="eversana"></div>
<div class="MuiGrid-root makeStyles-prolastinLogo-14 MuiGrid-item"><img
src="https://www.stg.rxcurie.com/media/prolastin/prolastin_logo.png" alt="prolastin"></div>
</div>
<div class="MuiGrid-root makeStyles-root-8 MuiGrid-container MuiGrid-direction-xs-column MuiGrid-wrap-xs-nowrap">
<div class="MuiGrid-root MuiGrid-item">
<div class="MuiPaper-root MuiPaper-elevation0">
<div>
<div class="MuiTypography-root makeStyles-pageTitle-11 MuiTypography-h6">Fax 1-866-588-6940</div>
<div class="MuiTypography-root makeStyles-pageTitle-11 MuiTypography-h6">PROLASTIN-C LIQUID Prescription
and Enrollment Form/SMN</div>
</div>
</div>
</div>
<div class="makeStyles-spacerSmall-6"></div>
<div class="MuiGrid-root MuiGrid-item">
<form novalidate="">
<div class="makeStyles-root-21">
<div
class="MuiPaper-root MuiAccordion-root makeStyles-accordionRoot-24 Mui-expanded MuiAccordion-rounded MuiPaper-elevation0 MuiPaper-rounded">
<div
class="MuiButtonBase-root MuiAccordionSummary-root makeStyles-accordionSummaryRoot-25 Mui-expanded makeStyles-accordionSummaryExpanded-26"
tabindex="0" role="button" aria-disabled="false" aria-expanded="true" aria-controls="panel1bh-content"
id="panel1bh-header">
<div
class="MuiAccordionSummary-content makeStyles-accordionSummaryContent-28 Mui-expanded makeStyles-accordionSummaryExpanded-26">
<p class="MuiTypography-root makeStyles-heading-22 MuiTypography-body1">Patient Information</p>
</div>
<div
class="MuiButtonBase-root MuiIconButton-root MuiAccordionSummary-expandIcon Mui-expanded makeStyles-accordionSummaryExpanded-26 MuiIconButton-edgeEnd"
aria-disabled="false" aria-hidden="true"><span class="MuiIconButton-label"><svg
class="MuiSvgIcon-root makeStyles-accordionSummaryExpandedIcon-27" focusable="false"
viewBox="0 0 24 24" aria-hidden="true">
<path d="M16.59 8.59L12 13.17 7.41 8.59 6 10l6 6 6-6z"></path>
</svg></span><span class="MuiTouchRipple-root"></span></div>
</div>
<div class="MuiCollapse-root MuiCollapse-entered" style="min-height: 0px;">
<div class="MuiCollapse-wrapper">
<div class="MuiCollapse-wrapperInner">
<div aria-labelledby="panel1bh-header" id="panel1bh-content" role="region">
<div class="MuiAccordionDetails-root">
<div class="MuiGrid-root makeStyles-gridContainer-43 MuiGrid-container">
<div class="MuiGrid-root makeStyles-gridItem-44 MuiGrid-item col-md-4 col-12">
<div class="MuiPaper-root makeStyles-paperRoot-37 MuiPaper-elevation0 MuiPaper-rounded">
<div
class="MuiFormControl-root MuiTextField-root col-md-4 col-12 makeStyles-textField-30 MuiFormControl-fullWidth">
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined "
data-shrink="false">Last Name</label>
<input aria-invalid="true" required name="patientInformation.lastName" type="text"
class="inputText MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>Last Name</span>
</legend>
</fieldset>
</div>
</div>
<div class="makeStyles-spacerSmall-35"></div>
<div
class="MuiFormControl-root col-md-4 col-12 MuiTextField-root makeStyles-textField-30 MuiFormControl-fullWidth">
<label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined "
data-shrink="false">First Name</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="true" name="patientInformation.firstName" type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>First Name</span>
</legend>
</fieldset>
</div>
</div>
<div class="makeStyles-spacerSmall-35"></div>
<div
class="MuiFormControl-root MuiTextField-root col-md-4 col-12 makeStyles-textField-30 MuiFormControl-fullWidth">
<label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined"
data-shrink="false">Middle Name</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" name="patientInformation.middleName" type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>Middle Name</span>
</legend>
</fieldset>
</div>
</div>
<div class="makeStyles-spacerSmall-35"></div>
<div
class="MuiFormControl-root MuiTextField-root col-md-4 col-12 makeStyles-textField-30 MuiFormControl-fullWidth">
<label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined"
data-shrink="false">Suffix</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" name="patientInformation.suffix" type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>Suffix</span>
</legend>
</fieldset>
</div>
</div>
<div class="makeStyles-spacerSmall-35"></div>
<div
class="MuiFormControl-root MuiTextField-root makeStyles-textField-30 MuiFormControl-fullWidth">
<span
class="MuiFormLabel-root dob_label MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-shrink MuiInputLabel-marginDense MuiInputLabel-outlined "
data-shrink="true">Date of Birth (DOB)</span>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="true" name="patientInformation.dob" type="date"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend
class="PrivateNotchedOutline-legendLabelled-47 PrivateNotchedOutline-legendNotched-48">
<span>Date of Birth (DOB)</span>
</legend>
</fieldset>
</div>
</div>
<div class="makeStyles-spacerSmall-35"></div>
<div class="MuiFormGroup-root MuiFormGroup-row align-items-center gender_field">
<legend class="MuiFormLabel-root makeStyles-caption-40 mb-0">Gender</legend><label
class="MuiFormControlLabel-root pl-1"><span
class="MuiButtonBase-root MuiIconButton-root PrivateSwitchBase-root-49 MuiCheckbox-root MuiCheckbox-colorPrimary MuiIconButton-colorPrimary"
aria-disabled="false"><span class="MuiIconButton-label"><input
class="PrivateSwitchBase-input-52" name="patientInformation.gender.male"
type="checkbox" data-indeterminate="false" value=""><svg
class="MuiSvgIcon-root" focusable="false" viewBox="0 0 24 24"
aria-hidden="true">
<path
d="M19 5v14H5V5h14m0-2H5c-1.1 0-2 .9-2 2v14c0 1.1.9 2 2 2h14c1.1 0 2-.9 2-2V5c0-1.1-.9-2-2-2z">
</path>
</svg></span><span class="MuiTouchRipple-root"></span></span><span
class="MuiTypography-root MuiFormControlLabel-label MuiTypography-body1">Male</span></label><label
class="MuiFormControlLabel-root"><span
class="MuiButtonBase-root MuiIconButton-root PrivateSwitchBase-root-49 MuiCheckbox-root MuiCheckbox-colorPrimary MuiIconButton-colorPrimary"
aria-disabled="false"><span class="MuiIconButton-label"><input
class="PrivateSwitchBase-input-52" name="patientInformation.gender.female"
type="checkbox" data-indeterminate="false" value=""><svg
class="MuiSvgIcon-root" focusable="false" viewBox="0 0 24 24"
aria-hidden="true">
<path
d="M19 5v14H5V5h14m0-2H5c-1.1 0-2 .9-2 2v14c0 1.1.9 2 2 2h14c1.1 0 2-.9 2-2V5c0-1.1-.9-2-2-2z">
</path>
</svg></span><span class="MuiTouchRipple-root"></span></span><span
class="MuiTypography-root MuiFormControlLabel-label MuiTypography-body1">Female</span></label>
</div>
</div>
</div>
<div class="MuiGrid-root makeStyles-gridItem-44 col-md-4 col-12 MuiGrid-item">
<div class="MuiPaper-root makeStyles-paperRoot-37 MuiPaper-elevation0 MuiPaper-rounded">
<div
class="MuiFormControl-root MuiTextField-root makeStyles-textField-30 MuiFormControl-fullWidth">
<label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined "
data-shrink="false">Address Line 1</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="true" name="patientInformation.address1" type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>Address Line
1</span></legend>
</fieldset>
</div>
</div>
<div class="makeStyles-spacerSmall-35"></div>
<div
class="MuiFormControl-root MuiTextField-root makeStyles-textField-30 MuiFormControl-fullWidth">
<label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined"
data-shrink="false">Address Line 2</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" name="patientInformation.address2" type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>Address Line
2</span></legend>
</fieldset>
</div>
</div>
<div class="makeStyles-spacerSmall-35"></div>
<div
class="MuiFormControl-root MuiTextField-root makeStyles-textField-30 MuiFormControl-fullWidth">
<label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined "
data-shrink="false">City</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="true" name="patientInformation.city" type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>City</span></legend>
</fieldset>
</div>
</div>
<div class="makeStyles-spacerSmall-35"></div>
<div class="MuiFormControl-root"><label
class="fevi_label MuiFormLabel-root MuiInputLabel-root makeStyles-formControlSelect-42 MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-outlined"
data-shrink="false" id="demo-simple-select-outlined-label">State</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-formControl height-40">
<select
class="MuiSelect-root MuiSelect-select MuiSelect-outlined MuiInputBase-input MuiOutlinedInput-input"
aria-invalid="false" id="patientInfoSelect" name="patientInformation.state">
<option value=""></option>
<option value="ohio">Ohio</option>
<option value="california">California</option>
<option value="New York">New York</option>
<option value="Texas">Texas</option>
<option value="Utah">Utah</option>
</select><svg class="MuiSvgIcon-root MuiSelect-icon MuiSelect-iconOutlined"
focusable="false" viewBox="0 0 24 24" aria-hidden="true">
<path d="M7 10l5 5 5-5z"></path>
</svg>
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>State</span>
</legend>
</fieldset>
</div>
</div>
<div class="makeStyles-spacerSmall-35"></div>
<div
class="MuiFormControl-root MuiTextField-root makeStyles-textField-30 MuiFormControl-fullWidth">
<label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined "
data-shrink="false">Zip Code</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="true" name="patientInformation.zipCode" type="number"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>Zip Code</span>
</legend>
</fieldset>
</div>
</div>
</div>
</div>
<div class="MuiGrid-root makeStyles-gridItem-44 col-md-4 col-12 MuiGrid-item">
<div class="MuiPaper-root makeStyles-paperRoot-37 MuiPaper-elevation0 MuiPaper-rounded">
<div
class="MuiFormControl-root MuiTextField-root makeStyles-textField-30 MuiFormControl-fullWidth">
<label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined "
data-shrink="false">Last four digits of Social Security</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="true" name="patientInformation.ssn" type="number"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>Last four digits of
Social Security</span></legend>
</fieldset>
</div>
</div>
<div class="makeStyles-spacerSmall-35"></div>
<div
class="MuiFormControl-root MuiTextField-root makeStyles-textField-30 MuiFormControl-fullWidth">
<label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined "
data-shrink="false">Home Phone</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="true" name="patientInformation.homePhone" type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>Home Phone</span>
</legend>
</fieldset>
</div>
</div>
<div class="makeStyles-spacerSmall-35"></div>
<div
class="MuiFormControl-root MuiTextField-root makeStyles-textField-30 MuiFormControl-fullWidth">
<label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined "
data-shrink="false">Cell/Other Phone</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="true" name="patientInformation.cellPhone" type="number"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>Cell/Other
Phone</span></legend>
</fieldset>
</div>
</div>
<div class="makeStyles-spacerSmall-35"></div>
<div
class="MuiFormControl-root MuiTextField-root makeStyles-textField-30 MuiFormControl-fullWidth">
<label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined "
data-shrink="false">Email</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="true" name="patientInformation.email" type="email"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>Email</span>
</legend>
</fieldset>
</div>
</div>
<div class="makeStyles-spacerSmall-35"></div>
<p class="makeStyles-caption-40 mb-0">Best time to reach me</p>
<div class="MuiFormGroup-root best_time MuiFormGroup-row flex-nowrap align-items-center">
<label class="MuiFormControlLabel-root mr-1"><span
class="MuiButtonBase-root MuiIconButton-root PrivateSwitchBase-root-49 MuiCheckbox-root MuiCheckbox-colorPrimary MuiIconButton-colorPrimary"
aria-disabled="false"><span class="MuiIconButton-label"><input
class="PrivateSwitchBase-input-52"
name="patientInformation.bestTimeToReach.morning" type="checkbox"
data-indeterminate="false" value=""><svg class="MuiSvgIcon-root"
focusable="false" viewBox="0 0 24 24" aria-hidden="true">
<path
d="M19 5v14H5V5h14m0-2H5c-1.1 0-2 .9-2 2v14c0 1.1.9 2 2 2h14c1.1 0 2-.9 2-2V5c0-1.1-.9-2-2-2z">
</path>
</svg></span><span class="MuiTouchRipple-root"></span></span><span
class="MuiTypography-root MuiFormControlLabel-label MuiTypography-body1">Morning</span></label><label
class="MuiFormControlLabel-root mr-1"><span
class="MuiButtonBase-root MuiIconButton-root PrivateSwitchBase-root-49 MuiCheckbox-root MuiCheckbox-colorPrimary MuiIconButton-colorPrimary"
aria-disabled="false"><span class="MuiIconButton-label"><input
class="PrivateSwitchBase-input-52"
name="patientInformation.bestTimeToReach.afternoon" type="checkbox"
data-indeterminate="false" value=""><svg class="MuiSvgIcon-root"
focusable="false" viewBox="0 0 24 24" aria-hidden="true">
<path
d="M19 5v14H5V5h14m0-2H5c-1.1 0-2 .9-2 2v14c0 1.1.9 2 2 2h14c1.1 0 2-.9 2-2V5c0-1.1-.9-2-2-2z">
</path>
</svg></span><span class="MuiTouchRipple-root"></span></span><span
class="MuiTypography-root MuiFormControlLabel-label MuiTypography-body1">Afternoon</span></label><label
class="MuiFormControlLabel-root mr-1"><span
class="MuiButtonBase-root MuiIconButton-root PrivateSwitchBase-root-49 MuiCheckbox-root MuiCheckbox-colorPrimary MuiIconButton-colorPrimary"
aria-disabled="false"><span class="MuiIconButton-label"><input
class="PrivateSwitchBase-input-52"
name="patientInformation.bestTimeToReach.evening" type="checkbox"
data-indeterminate="false" value=""><svg class="MuiSvgIcon-root"
focusable="false" viewBox="0 0 24 24" aria-hidden="true">
<path
d="M19 5v14H5V5h14m0-2H5c-1.1 0-2 .9-2 2v14c0 1.1.9 2 2 2h14c1.1 0 2-.9 2-2V5c0-1.1-.9-2-2-2z">
</path>
</svg></span><span class="MuiTouchRipple-root"></span></span><span
class="MuiTypography-root MuiFormControlLabel-label MuiTypography-body1">Evening</span></label>
</div>
</div>
</div>
</div>
<p class="makeStyles-caption-40 text-left hours_of_op">PROLASTIN DIRECT Hours of Operation: 7am-7pm CST</p>
<div class="makeStyles-spacer-17"></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="makeStyles-spacerMedium-18"></div>
<div
class="MuiPaper-root MuiAccordion-root makeStyles-accordionRoot-24 Mui-expanded MuiAccordion-rounded MuiPaper-elevation0 MuiPaper-rounded">
<div
class="MuiButtonBase-root MuiAccordionSummary-root makeStyles-accordionSummaryRoot-25 Mui-expanded makeStyles-accordionSummaryExpanded-26"
tabindex="0" role="button" aria-disabled="false" aria-expanded="true" aria-controls="panel1bh-content"
id="panel1bh-header">
<div
class="MuiAccordionSummary-content makeStyles-accordionSummaryContent-28 Mui-expanded makeStyles-accordionSummaryExpanded-26">
<p class="MuiTypography-root makeStyles-heading-22 MuiTypography-body1">Medical Information</p>
</div>
<div
class="MuiButtonBase-root MuiIconButton-root MuiAccordionSummary-expandIcon Mui-expanded makeStyles-accordionSummaryExpanded-26 MuiIconButton-edgeEnd"
aria-disabled="false" aria-hidden="true"><span class="MuiIconButton-label"><svg
class="MuiSvgIcon-root makeStyles-accordionSummaryExpandedIcon-27" focusable="false"
viewBox="0 0 24 24" aria-hidden="true">
<path d="M16.59 8.59L12 13.17 7.41 8.59 6 10l6 6 6-6z"></path>
</svg></span><span class="MuiTouchRipple-root"></span></div>
</div>
<div class="MuiCollapse-root MuiCollapse-entered" style="min-height: 0px; margin-top: 30px;">
<div class="MuiCollapse-wrapper">
<div class="MuiCollapse-wrapperInner">
<div aria-labelledby="panel1bh-header" id="panel1bh-content" role="region">
<div class="MuiAccordionDetails-root pb-0">
<div
class="MuiGrid-root MuiGrid-container MuiGrid-direction-xs-column MuiGrid-wrap-xs-nowrap">
<div
class="MuiPaper-root makeStyles-paperRoot-58 MuiPaper-elevation0 MuiPaper-rounded MuiFormControl-fullWidth">
<div class="MuiFormControl-root makeStyles-formControl-53 col-md-7 col-12 mb-0"><label
class="fevi_label MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-outlined"
data-shrink="false" id="simple-select-outlined-label">ICD-10 Diagnosis</label>
<div class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-formControl height-40">
<select
class="MuiSelect-root icdSelect MuiSelect-select MuiSelect-outlined MuiInputBase-input MuiOutlinedInput-input"
aria-invalid="false" id="icdDiagnosis" name="medicalInformation.icdDiagnosis">
<option class="makeStyles-selectMenuItem-60" value=""></option>
<option value="Alpha1Antitrypsin">Alpha1- Antitrypsin Deficiency E88.01</option>
<option value="PanlobularEmphysema">Panlobular Emphysema J43.1</option>
<option value="other">Other ICD-10</option>
</select><svg class="MuiSvgIcon-root MuiSelect-icon MuiSelect-iconOutlined"
focusable="false" viewBox="0 0 24 24" aria-hidden="true">
<path d="M7 10l5 5 5-5z"></path>
</svg>
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>diagnosis</span>
</legend>
</fieldset>
</div>
</div>
<div class="MuiFormControl-root col-md-4 col-12 MuiTextField-root makeStyles-textField-30 othericd">
<label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined "
data-shrink="false">Other ICD-10</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="true" name="patientInformation.othericd10" type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>Other ICD-10</span>
</legend>
</fieldset>
</div>
</div>
</div>
<div class="makeStyles-spacerSmall-56"></div>
</div>
<div
class="MuiGrid-root MuiGrid-container MuiGrid-direction-xs-column MuiGrid-wrap-xs-nowrap">
<div class="MuiGrid-root makeStyles-item1-65 MuiGrid-item">
<div class="MuiPaper-root makeStyles-paperItem-61 MuiPaper-elevation0 MuiPaper-rounded">
<div class="MuiFormControl-root MuiTextField-root makeStyles-textField-62 col-md-4 col-12"><label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined"
data-shrink="false">AAT Phenotype</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" name="medicalInformation.aat" type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>AAT Phenotype</span>
</legend>
</fieldset>
</div>
</div>
<div class="MuiFormControl-root makeStyles-formControl-53 col-md-4 col-12">
<div class="MuiFormControl-root MuiTextField-root makeStyles-textField-62" style="width:100%;"
aria-describedby="outlined-weight-helper-text"><label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined"
data-shrink="false" for="outlined-adornment-weight"
id="outlined-adornment-weight-label">FEV1</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-formControl MuiInputBase-adornedEnd MuiOutlinedInput-adornedEnd MuiInputBase-marginDense MuiOutlinedInput-marginDense"
aria-label="FEV1"><input aria-invalid="false" id="outlined-adornment-weight"
type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputAdornedEnd MuiOutlinedInput-inputAdornedEnd MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<div
class="MuiInputAdornment-root MuiInputAdornment-positionEnd MuiInputAdornment-marginDense">
<p
class="MuiTypography-root MuiTypography-body1 MuiTypography-colorTextSecondary">
% predicted</p>
</div>
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>FEV1</span>
</legend>
</fieldset>
</div>
</div>
</div>
<div class="MuiFormControl-root makeStyles-formControl-53 col-md-4 col-12">
<div class="MuiFormControl-root MuiTextField-root makeStyles-textField-62"
aria-describedby="outlined-weight-helper-text"><label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined"
data-shrink="false" for="outlined-adornment-weight"
id="outlined-adornment-weight-label">DLCO</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-formControl MuiInputBase-adornedEnd MuiOutlinedInput-adornedEnd MuiInputBase-marginDense MuiOutlinedInput-marginDense"
aria-label="DLCO"><input aria-invalid="false" id="outlined-adornment-weight"
type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputAdornedEnd MuiOutlinedInput-inputAdornedEnd MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<div
class="MuiInputAdornment-root MuiInputAdornment-positionEnd MuiInputAdornment-marginDense">
<p
class="MuiTypography-root MuiTypography-body1 MuiTypography-colorTextSecondary">
% predicted</p>
</div>
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>DLCO</span>
</legend>
</fieldset>
</div>
</div>
<div class="makeStyles-spacerSmall-56"></div>
</div>
</div>
<div class="makeStyles-spacerSmall-56"></div>
<div
class="makeStyles-paperItem-61-2 MuiPaper-elevation0 MuiPaper-rounded">
<div class="MuiFormControl-root makeStyles-formControl-53 col-md-4 col-12">
<div class="MuiFormControl-root MuiTextField-root makeStyles-textField-62"
aria-describedby="outlined-weight-helper-text"><label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined"
data-shrink="false" for="outlined-adornment-weight"
id="outlined-adornment-weight-label">Serum AAT Level</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-formControl MuiInputBase-adornedEnd MuiOutlinedInput-adornedEnd MuiInputBase-marginDense MuiOutlinedInput-marginDense"
aria-label="Serum AAT Level"><input aria-invalid="false" id="outlined-adornment-weight"
type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputAdornedEnd MuiOutlinedInput-inputAdornedEnd MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<div
class="MuiInputAdornment-root MuiInputAdornment-positionEnd MuiInputAdornment-marginDense">
<p
class="MuiTypography-root MuiTypography-body1 MuiTypography-colorTextSecondary">
mg/dL</p>
</div>
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>DLCO</span>
</legend>
</fieldset>
</div>
</div>
<div class="makeStyles-spacerSmall-56"></div>
</div>
<div class="MuiFormControl-root makeStyles-formControl-53 col-md-4 col-12">
<div class="MuiFormControl-root MuiTextField-root makeStyles-textField-62"
aria-describedby="outlined-weight-helper-text"><label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined"
data-shrink="false" for="outlined-adornment-weight"
id="outlined-adornment-weight-label">Serum AAT Level</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-formControl MuiInputBase-adornedEnd MuiOutlinedInput-adornedEnd MuiInputBase-marginDense MuiOutlinedInput-marginDense"
aria-label="Serum AAT Level"><input aria-invalid="false" id="outlined-adornment-weight"
type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputAdornedEnd MuiOutlinedInput-inputAdornedEnd MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<div
class="MuiInputAdornment-root MuiInputAdornment-positionEnd MuiInputAdornment-marginDense">
<p
class="MuiTypography-root MuiTypography-body1 MuiTypography-colorTextSecondary">
µM</p>
</div>
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>Serum AAT Level</span>
</legend>
</fieldset>
</div>
</div>
<div class="makeStyles-spacerSmall-56"></div>
</div>
<div class="MuiFormControl-root makeStyles-formControlWeight-63 col-md-4 col-12">
<div class="MuiFormControl-root MuiTextField-root makeStyles-textField-62 col-md-10 col-10"
aria-describedby="outlined-weight-helper-text"><label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined"
data-shrink="false" for="outlined-adornment-weight"
id="outlined-adornment-weight-label">Weight</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" id="outlined-adornment-weight" type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>Weight</span>
</legend>
</fieldset>
</div>
</div>
<div class="MuiFormControl-root makeStyles-margin-66 col-md-2 col-2"><label
class="weightUnitsLabel MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-shrink"
data-shrink="true" id="simple-select-outlined-label">weight in</label>
<div
class="MuiInputBase-root MuiInput-root MuiInput-underline MuiInputBase-formControl MuiInput-formControl">
<select class="MuiSelect-root MuiSelect-select MuiInputBase-input MuiInput-input"
aria-invalid="false" id="weightUnits" name="medicalInformation.weight.unit">
<option class="makeStyles-selectMenuItem-60" value=""></option>
<option value="Kg">Kg</option>
<option value="lbs">lbs</option>
</select><svg class="MuiSvgIcon-root MuiSelect-icon" focusable="false"
viewBox="0 0 24 24" aria-hidden="true">
<path d="M7 10l5 5 5-5z"></path>
</svg>
</div>
</div>
</div>
</div>
<div class="makeStyles-paperItem-61-3 MuiPaper-elevation0 MuiPaper-rounded" style="padding: 0 22px;">
<div class="MuiFormGroup-root allergies_group">
<div class="MuiFormLabel-root">Allergies</div>
<label class="MuiFormControlLabel-root"><span
class="MuiButtonBase-root MuiIconButton-root PrivateSwitchBase-root-49 MuiCheckbox-root MuiCheckbox-colorPrimary MuiIconButton-colorPrimary"
aria-disabled="false"><span class="MuiIconButton-label"><input
class="PrivateSwitchBase-input-52" name="medicalInformation.allergies.none"
type="checkbox" data-indeterminate="false" value=""><svg
class="MuiSvgIcon-root" focusable="false" viewBox="0 0 24 24"
aria-hidden="true">
<path
d="M19 5v14H5V5h14m0-2H5c-1.1 0-2 .9-2 2v14c0 1.1.9 2 2 2h14c1.1 0 2-.9 2-2V5c0-1.1-.9-2-2-2z">
</path>
</svg></span><span class="MuiTouchRipple-root"></span></span><span
class="MuiTypography-root MuiFormControlLabel-label MuiTypography-body1">None</span></label><label
class="MuiFormControlLabel-root"><span
class="MuiButtonBase-root MuiIconButton-root PrivateSwitchBase-root-49 MuiCheckbox-root MuiCheckbox-colorPrimary MuiIconButton-colorPrimary"
aria-disabled="false"><span class="MuiIconButton-label"><input
class="PrivateSwitchBase-input-52 specify_checkbox" name="medicalInformation.allergies.specify"
type="checkbox" data-indeterminate="false" value=""><svg
class="MuiSvgIcon-root" focusable="false" viewBox="0 0 24 24"
aria-hidden="true">
<path
d="M19 5v14H5V5h14m0-2H5c-1.1 0-2 .9-2 2v14c0 1.1.9 2 2 2h14c1.1 0 2-.9 2-2V5c0-1.1-.9-2-2-2z">
</path>
</svg></span><span class="MuiTouchRipple-root"></span></span><span
class="MuiTypography-root MuiFormControlLabel-label MuiTypography-body1">Specific</span></label>
<div class="MuiFormControl-root MuiTextField-root makeStyles-textField-62 specify_field"><label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined"
data-shrink="false">Specific</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" name="medicalInformation.allergies.specify"
type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>Specific</span>
</legend>
</fieldset>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="makeStyles-spacer-17"></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="makeStyles-spacerMedium-18"></div>
<div
class="MuiPaper-root MuiAccordion-root makeStyles-accordionRoot-24 Mui-expanded MuiAccordion-rounded MuiPaper-elevation0 MuiPaper-rounded">
<div
class="MuiButtonBase-root MuiAccordionSummary-root makeStyles-accordionSummaryRoot-25 Mui-expanded makeStyles-accordionSummaryExpanded-26"
tabindex="0" role="button" aria-disabled="false" aria-expanded="true" aria-controls="panel1bh-content"
id="panel1bh-header">
<div
class="MuiAccordionSummary-content makeStyles-accordionSummaryContent-28 Mui-expanded makeStyles-accordionSummaryExpanded-26">
<p class="MuiTypography-root makeStyles-heading-22 MuiTypography-body1">PROLASTIN-C LIQUID
Prescription/Orders</p>
</div>
<div
class="MuiButtonBase-root MuiIconButton-root MuiAccordionSummary-expandIcon Mui-expanded makeStyles-accordionSummaryExpanded-26 MuiIconButton-edgeEnd"
aria-disabled="false" aria-hidden="true"><span class="MuiIconButton-label"><svg
class="MuiSvgIcon-root makeStyles-accordionSummaryExpandedIcon-27" focusable="false"
viewBox="0 0 24 24" aria-hidden="true">
<path d="M16.59 8.59L12 13.17 7.41 8.59 6 10l6 6 6-6z"></path>
</svg></span><span class="MuiTouchRipple-root"></span></div>
</div>
<div class="MuiCollapse-root MuiCollapse-entered" style="min-height: 0px;">
<div class="MuiCollapse-wrapper">
<div class="MuiCollapse-wrapperInner">
<div aria-labelledby="panel1bh-header" id="panel1bh-content" role="region">
<div class="MuiAccordionDetails-root">
<div class="MuiGrid-root makeStyles-gridContainer-79 MuiGrid-container">
<div class="MuiPaper-root makeStyles-paperRoot-75 MuiPaper-elevation0 MuiPaper-rounded">
<div
class="MuiGrid-root makeStyles-gridItem-80 MuiGrid-container MuiGrid-item MuiGrid-direction-xs-column">
<h6 class="MuiTypography-root makeStyles-title-81 MuiTypography-h6">PROLASTIN-C LIQUID
</h6><span>(alpha1-proteinase inhibitor [human])</span>
<div class="makeStyles-spacerSmall-73"></div>
<div class="makeStyles-itemContents-83">
<div class="MuiGrid-root makeStyles-items-82 MuiGrid-item">
<h6 class="MuiTypography-root makeStyles-title-81 MuiTypography-h6">Number of
Refills:</h6>
<div class="MuiFormGroup-root"><label class="MuiFormControlLabel-root"><span
class="MuiButtonBase-root MuiIconButton-root PrivateSwitchBase-root-49 MuiCheckbox-root MuiCheckbox-colorPrimary MuiIconButton-colorPrimary"
aria-disabled="false"><span class="MuiIconButton-label"><input
class="PrivateSwitchBase-input-52" name="prescription.refills.months"
type="checkbox" data-indeterminate="false" value=""><svg
class="MuiSvgIcon-root" focusable="false" viewBox="0 0 24 24"
aria-hidden="true">
<path
d="M19 5v14H5V5h14m0-2H5c-1.1 0-2 .9-2 2v14c0 1.1.9 2 2 2h14c1.1 0 2-.9 2-2V5c0-1.1-.9-2-2-2z">
</path>
</svg></span><span class="MuiTouchRipple-root"></span></span><span
class="MuiTypography-root MuiFormControlLabel-label MuiTypography-body1">12
months Dispense up to a 30-day supply</span></label><label
class="MuiFormControlLabel-root"><span
class="MuiButtonBase-root MuiIconButton-root PrivateSwitchBase-root-49 MuiCheckbox-root MuiCheckbox-colorPrimary MuiIconButton-colorPrimary"
aria-disabled="false"><span class="MuiIconButton-label"><input
class="PrivateSwitchBase-input-52" name="prescription.refills.others"
type="checkbox" data-indeterminate="false" value=""><svg
class="MuiSvgIcon-root" focusable="false" viewBox="0 0 24 24"
aria-hidden="true">
<path
d="M19 5v14H5V5h14m0-2H5c-1.1 0-2 .9-2 2v14c0 1.1.9 2 2 2h14c1.1 0 2-.9 2-2V5c0-1.1-.9-2-2-2z">
</path>
</svg></span><span class="MuiTouchRipple-root"></span></span><span
class="MuiTypography-root MuiFormControlLabel-label MuiTypography-body1">Other
number of Refills</span></label>
<div class="MuiFormControl-root MuiTextField-root">
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" id="other" type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline"
style="padding-left: 8px;">
<legend class="PrivateNotchedOutline-legend-46" style="width: 0.01px;">
<span>​</span>
</legend>
</fieldset>
</div>
</div>
</div>
</div>
<div class="MuiGrid-root makeStyles-items-82 MuiGrid-item">
<h6 class="MuiTypography-root makeStyles-title-81 MuiTypography-h6">Rate:</h6>
<div class="MuiFormGroup-root"><label class="MuiFormControlLabel-root"><span
class="MuiButtonBase-root MuiIconButton-root PrivateSwitchBase-root-49 MuiCheckbox-root MuiCheckbox-colorPrimary MuiIconButton-colorPrimary"
aria-disabled="false"><span class="MuiIconButton-label"><input
class="PrivateSwitchBase-input-52" name="prescription.rate.tolerance"
type="checkbox" data-indeterminate="false" value=""><svg
class="MuiSvgIcon-root" focusable="false" viewBox="0 0 24 24"
aria-hidden="true">
<path
d="M19 5v14H5V5h14m0-2H5c-1.1 0-2 .9-2 2v14c0 1.1.9 2 2 2h14c1.1 0 2-.9 2-2V5c0-1.1-.9-2-2-2z">
</path>
</svg></span><span class="MuiTouchRipple-root"></span></span><span
class="MuiTypography-root MuiFormControlLabel-label MuiTypography-body1">As
tolerated by patient up to 0.08 mL/kg/min</span></label><label
class="MuiFormControlLabel-root"><span
class="MuiButtonBase-root MuiIconButton-root PrivateSwitchBase-root-49 MuiCheckbox-root MuiCheckbox-colorPrimary MuiIconButton-colorPrimary"
aria-disabled="false"><span class="MuiIconButton-label"><input
class="PrivateSwitchBase-input-52" name="prescription.rate.others"
type="checkbox" data-indeterminate="false" value=""><svg
class="MuiSvgIcon-root" focusable="false" viewBox="0 0 24 24"
aria-hidden="true">
<path
d="M19 5v14H5V5h14m0-2H5c-1.1 0-2 .9-2 2v14c0 1.1.9 2 2 2h14c1.1 0 2-.9 2-2V5c0-1.1-.9-2-2-2z">
</path>
</svg></span><span class="MuiTouchRipple-root"></span></span><span
class="MuiTypography-root MuiFormControlLabel-label MuiTypography-body1">Other
rate</span></label>
<div class="MuiFormControl-root MuiTextField-root">
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" id="other" type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline"
style="padding-left: 8px;">
<legend class="PrivateNotchedOutline-legend-46" style="width: 0.01px;">
<span>​</span>
</legend>
</fieldset>
</div>
</div>
</div>
</div>
<div class="MuiGrid-root makeStyles-items-82 MuiGrid-item">
<h6 class="MuiTypography-root makeStyles-title-81 MuiTypography-h6">Dosage:</h6>
<div class="MuiFormGroup-root"><label class="MuiFormControlLabel-root"><span
class="MuiButtonBase-root MuiIconButton-root PrivateSwitchBase-root-49 MuiCheckbox-root MuiCheckbox-colorPrimary MuiIconButton-colorPrimary"
aria-disabled="false"><span class="MuiIconButton-label"><input
class="PrivateSwitchBase-input-52" name="prescription.dose.weekly"
type="checkbox" data-indeterminate="false" value=""><svg
class="MuiSvgIcon-root" focusable="false" viewBox="0 0 24 24"
aria-hidden="true">
<path
d="M19 5v14H5V5h14m0-2H5c-1.1 0-2 .9-2 2v14c0 1.1.9 2 2 2h14c1.1 0 2-.9 2-2V5c0-1.1-.9-2-2-2z">
</path>
</svg></span><span class="MuiTouchRipple-root"></span></span><span
class="MuiTypography-root MuiFormControlLabel-label MuiTypography-body1">60
mg/kg (+/-10%) IV weekly</span></label><label
class="MuiFormControlLabel-root"><span
class="MuiButtonBase-root MuiIconButton-root PrivateSwitchBase-root-49 MuiCheckbox-root MuiCheckbox-colorPrimary MuiIconButton-colorPrimary"
aria-disabled="false"><span class="MuiIconButton-label"><input
class="PrivateSwitchBase-input-52" name="prescription.dose.others"
type="checkbox" data-indeterminate="false" value=""><svg
class="MuiSvgIcon-root" focusable="false" viewBox="0 0 24 24"
aria-hidden="true">
<path
d="M19 5v14H5V5h14m0-2H5c-1.1 0-2 .9-2 2v14c0 1.1.9 2 2 2h14c1.1 0 2-.9 2-2V5c0-1.1-.9-2-2-2z">
</path>
</svg></span><span class="MuiTouchRipple-root"></span></span><span
class="MuiTypography-root MuiFormControlLabel-label MuiTypography-body1">Other
dose/frequency</span></label>
<div class="MuiFormControl-root MuiTextField-root">
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" id="other" type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline"
style="padding-left: 8px;">
<legend class="PrivateNotchedOutline-legend-46" style="width: 0.01px;">
<span>​</span>
</legend>
</fieldset>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="makeStyles-spacerSmall-73"></div>
<div class="MuiGrid-root makeStyles-gridItem-80 MuiGrid-item MuiGrid-direction-xs-column">
<div class="MuiFormGroup-root"><label
class="MuiFormControlLabel-root makeStyles-formControl-84"><span
class="MuiButtonBase-root MuiIconButton-root PrivateSwitchBase-root-49 MuiCheckbox-root MuiCheckbox-colorPrimary MuiIconButton-colorPrimary"
aria-disabled="false"><span class="MuiIconButton-label"><input
class="PrivateSwitchBase-input-52" name="prescription.autodevice"
type="checkbox" data-indeterminate="false" value=""><svg class="MuiSvgIcon-root"
focusable="false" viewBox="0 0 24 24" aria-hidden="true">
<path
d="M19 5v14H5V5h14m0-2H5c-1.1 0-2 .9-2 2v14c0 1.1.9 2 2 2h14c1.1 0 2-.9 2-2V5c0-1.1-.9-2-2-2z">
</path>
</svg></span><span class="MuiTouchRipple-root"></span></span><span
class="MuiTypography-root MuiFormControlLabel-label MuiTypography-body1">Epinephrine
Inj Auto 0.3 mg/0.3 mL. Inject from autodevice, prn, for allergic reaction
</span></label></div>
</div>
<div class="makeStyles-spacerSmall-73"></div>
<div class="MuiGrid-root makeStyles-gridItem-80 MuiGrid-item MuiGrid-direction-xs-column">
<div class="MuiFormGroup-root"><label
class="MuiFormControlLabel-root makeStyles-formControl-84"><span
class="MuiButtonBase-root MuiIconButton-root PrivateSwitchBase-root-49 MuiCheckbox-root MuiCheckbox-colorPrimary MuiIconButton-colorPrimary"
aria-disabled="false"><span class="MuiIconButton-label"><input
class="PrivateSwitchBase-input-52" name="prescription.EMLA" type="checkbox"
data-indeterminate="false" value=""><svg class="MuiSvgIcon-root"
focusable="false" viewBox="0 0 24 24" aria-hidden="true">
<path
d="M19 5v14H5V5h14m0-2H5c-1.1 0-2 .9-2 2v14c0 1.1.9 2 2 2h14c1.1 0 2-.9 2-2V5c0-1.1-.9-2-2-2z">
</path>
</svg></span><span class="MuiTouchRipple-root"></span></span><span
class="MuiTypography-root MuiFormControlLabel-label MuiTypography-body1">EMLA or
lidocaine 2.5%/prilocaine 2.5%:Apply 2.5g over 20-25cm^2 of skin surface at least
1 hour prior to puncture </span></label></div>
</div>
<div class="makeStyles-spacerSmall-73"></div>
<div class="MuiGrid-root makeStyles-gridItem-80 MuiGrid-item MuiGrid-direction-xs-column">
<div class="MuiFormGroup-root"><label
class="MuiFormControlLabel-root makeStyles-formControl-84"><span
class="MuiButtonBase-root MuiIconButton-root PrivateSwitchBase-root-49 MuiCheckbox-root MuiCheckbox-colorPrimary MuiIconButton-colorPrimary"
aria-disabled="false"><span class="MuiIconButton-label"><input
class="PrivateSwitchBase-input-52" name="prescription.premedication"
type="checkbox" data-indeterminate="false" value=""><svg class="MuiSvgIcon-root"
focusable="false" viewBox="0 0 24 24" aria-hidden="true">
<path
d="M19 5v14H5V5h14m0-2H5c-1.1 0-2 .9-2 2v14c0 1.1.9 2 2 2h14c1.1 0 2-.9 2-2V5c0-1.1-.9-2-2-2z">
</path>
</svg></span><span class="MuiTouchRipple-root"></span></span><span
class="MuiTypography-root MuiFormControlLabel-label MuiTypography-body1">Premedication/Other
orders: </span></label>
<div class="MuiFormControl-root MuiTextField-root" style="padding: 5px 10px;">
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" id="other" type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline"
style="padding-left: 8px;">
<legend class="PrivateNotchedOutline-legend-46" style="width: 0.01px;">
<span>​</span>
</legend>
</fieldset>
</div>
</div>
</div>
</div>
<div class="makeStyles-spacerSmall-73"></div>
<div class="MuiGrid-root makeStyles-gridItem-80 MuiGrid-item MuiGrid-direction-xs-column">
<p class="MuiTypography-root MuiTypography-body1"
style="padding: 5px; font-size: 14.5px;">
Monitor patient including VS<strong> before,
Q15 during, and 5 minutes post infusion</strong></p>
<div class="makeStyles-spacerExtraSmall-74"></div>
<p class="MuiTypography-root MuiTypography-body1"
style="padding: 5px; font-size: 14.5px;">
Provide medical supplies, including syringes
and needles, to safely administer prescribed medication</p>
<div class="makeStyles-spacerExtraSmall-74"></div>
<p class="MuiTypography-root MuiTypography-body1"
style="padding: 5px; font-size: 14.5px;">
Skilled nursing visits for medication
administration, assessment, and teaching</p>
</div>
</div>
<div class="MuiPaper-root makeStyles-paperRoot-75 MuiPaper-elevation0 MuiPaper-rounded">
<div class="MuiGrid-root makeStyles-gridItem-80 MuiGrid-item MuiGrid-direction-xs-column">
<h6 class="MuiTypography-root makeStyles-title-81 MuiTypography-h6">Intravenous Access
and Flush Orders:</h6>
<div class="MuiFormGroup-root"><label class="MuiFormControlLabel-root"><span
class="MuiButtonBase-root MuiIconButton-root PrivateSwitchBase-root-49 MuiCheckbox-root MuiCheckbox-colorPrimary MuiIconButton-colorPrimary"
aria-disabled="false"><span class="MuiIconButton-label"><input
class="PrivateSwitchBase-input-52" name="prescription.flushOrders.peripheral"
type="checkbox" data-indeterminate="false" value=""><svg class="MuiSvgIcon-root"
focusable="false" viewBox="0 0 24 24" aria-hidden="true">
<path
d="M19 5v14H5V5h14m0-2H5c-1.1 0-2 .9-2 2v14c0 1.1.9 2 2 2h14c1.1 0 2-.9 2-2V5c0-1.1-.9-2-2-2z">
</path>
</svg></span><span class="MuiTouchRipple-root"></span></span><span
class="MuiTypography-root MuiFormControlLabel-label MuiTypography-body1">Peripheral
IV line </span></label><label
class="MuiFormLabel-root makeStyles-formLabel-85">Normal
saline: 3-5mL before
infusion and 3-5mL after infusion OR <br> <div
class="MuiFormControl-root MuiTextField-root mt-3">
<label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined"
data-shrink="false" for="other" id="other-label">Other</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" id="other" type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>Other</span>
</legend>
</fieldset>
</div>
</div></label><label class="MuiFormControlLabel-root"><span
class="MuiButtonBase-root MuiIconButton-root PrivateSwitchBase-root-49 MuiCheckbox-root MuiCheckbox-colorPrimary MuiIconButton-colorPrimary"
aria-disabled="false"><span class="MuiIconButton-label"><input
class="PrivateSwitchBase-input-52" name="prescription.flushOrders.implanted"
type="checkbox" data-indeterminate="false" value=""><svg class="MuiSvgIcon-root"
focusable="false" viewBox="0 0 24 24" aria-hidden="true">
<path
d="M19 5v14H5V5h14m0-2H5c-1.1 0-2 .9-2 2v14c0 1.1.9 2 2 2h14c1.1 0 2-.9 2-2V5c0-1.1-.9-2-2-2z">
</path>
</svg></span><span class="MuiTouchRipple-root"></span></span><span
class="MuiTypography-root MuiFormControlLabel-label MuiTypography-body1">Implanted
Port/Central Line (each lumen)</span></label><label
class="MuiFormLabel-root makeStyles-formLabel-85">Normal saline: 5-10mL before
infusion and 5-10mL after infusion</label><label
class="MuiFormLabel-root makeStyles-formLabel-85">Heparin: 100 units/mL, 5 mL after
infusion, and<div class="MuiFormControl-root MuiTextField-root mt-3"><label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined"
data-shrink="false" for="other" id="other-label">Other (frequency)</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" id="other" type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>Other
(frequency)</span></legend>
</fieldset>
</div>
</div></label></div>
</div>
<div class="makeStyles-spacerSmall-73"></div>
<div class="MuiGrid-root makeStyles-gridItem-80 MuiGrid-item MuiGrid-direction-xs-column">
<h6 class="MuiTypography-root makeStyles-title-81 MuiTypography-h6">First Dose Location
Preference(s):</h6>
<div class="MuiFormGroup-root"><label class="MuiFormControlLabel-root"><span
class="MuiButtonBase-root MuiIconButton-root PrivateSwitchBase-root-49 MuiCheckbox-root MuiCheckbox-colorPrimary MuiIconButton-colorPrimary"
aria-disabled="false"><span class="MuiIconButton-label"><input
class="PrivateSwitchBase-input-52" name="prescription.doseLocation.home"
type="checkbox" data-indeterminate="false" value=""><svg class="MuiSvgIcon-root"
focusable="false" viewBox="0 0 24 24" aria-hidden="true">
<path
d="M19 5v14H5V5h14m0-2H5c-1.1 0-2 .9-2 2v14c0 1.1.9 2 2 2h14c1.1 0 2-.9 2-2V5c0-1.1-.9-2-2-2z">
</path>
</svg></span><span class="MuiTouchRipple-root"></span></span><span
class="MuiTypography-root MuiFormControlLabel-label MuiTypography-body1">Home
</span></label><label class="MuiFormControlLabel-root"><span
class="MuiButtonBase-root MuiIconButton-root PrivateSwitchBase-root-49 MuiCheckbox-root MuiCheckbox-colorPrimary MuiIconButton-colorPrimary"
aria-disabled="false"><span class="MuiIconButton-label"><input
class="PrivateSwitchBase-input-52"
name="prescription.doseLocation.medicalFacility" type="checkbox"
data-indeterminate="false" value=""><svg class="MuiSvgIcon-root"
focusable="false" viewBox="0 0 24 24" aria-hidden="true">
<path
d="M19 5v14H5V5h14m0-2H5c-1.1 0-2 .9-2 2v14c0 1.1.9 2 2 2h14c1.1 0 2-.9 2-2V5c0-1.1-.9-2-2-2z">
</path>
</svg></span><span class="MuiTouchRipple-root"></span></span><span
class="MuiTypography-root MuiFormControlLabel-label MuiTypography-body1">Medical
facility (name, phone of preferred facility, if any):</span></label>
<div class="MuiFormControl-root MuiTextField-root">
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" id="other" type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline"
style="padding-left: 8px;">
<legend class="PrivateNotchedOutline-legend-46" style="width: 0.01px;">
<span>​</span>
</legend>
</fieldset>
</div>
</div><label class="MuiFormLabel-root" style="color: rgb(0, 0, 0); padding: 10px;">List
of
facilities where physician has
privileges:</label>
<div class="MuiFormControl-root MuiTextField-root">
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" id="other" type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline"
style="padding-left: 8px;">
<legend class="PrivateNotchedOutline-legend-46" style="width: 0.01px;">
<span>​</span>
</legend>
</fieldset>
</div>
</div>
</div>
</div>
<div class="makeStyles-spacerSmall-73"></div>
<div class="MuiGrid-root makeStyles-gridItem-80 MuiGrid-item MuiGrid-direction-xs-column">
<h6 class="MuiTypography-root makeStyles-title-81 MuiTypography-h6">First Dose in Home
Orders:</h6>
<p class="MuiTypography-root MuiTypography-body1"
style="padding: 5px; font-size: 14.5px;">
Establish primary IV line with 250-500 mL of
normal saline OR
<div class="MuiFormControl-root MuiTextField-root" style="height: 0px;">
<div
class="MuiInputBase-root MuiInput-root MuiInput-underline MuiInputBase-formControl MuiInput-formControl MuiInputBase-marginDense MuiInput-marginDense">
<input aria-invalid="false" id="standard-basic" type="text"
class="MuiInputBase-input MuiInput-input MuiInputBase-inputMarginDense MuiInput-inputMarginDense"
value="">
</div>
</div>at KVO rate prior to infusion</p>
<p class="MuiTypography-root MuiTypography-body1"
style="padding: 5px; font-size: 14.5px;">
Monitor patient including VS before, Q15
during and 30 minutes post infusion Diphenhydramine 25-50 mg IV as directed for severe
allergic reaction or anaphylaxis</p>
</div>
</div>
</div>
<div class="note">*EVERSANA is the exclusive dispensing pharmacy for PROLASTIN-C LIQUID</div>
<div class="makeStyles-spacer-17"></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="makeStyles-spacerMedium-18"></div>
<div
class="MuiPaper-root MuiAccordion-root makeStyles-accordionRoot-24 Mui-expanded MuiAccordion-rounded MuiPaper-elevation0 MuiPaper-rounded">
<div
class="MuiButtonBase-root MuiAccordionSummary-root makeStyles-accordionSummaryRoot-25 Mui-expanded makeStyles-accordionSummaryExpanded-26"
tabindex="0" role="button" aria-disabled="false" aria-expanded="true" aria-controls="panel1bh-content"
id="panel1bh-header">
<div
class="MuiAccordionSummary-content makeStyles-accordionSummaryContent-28 Mui-expanded makeStyles-accordionSummaryExpanded-26">
<p class="MuiTypography-root makeStyles-heading-22 MuiTypography-body1">Physician/Office Information
</p>
</div>
<div
class="MuiButtonBase-root MuiIconButton-root MuiAccordionSummary-expandIcon Mui-expanded makeStyles-accordionSummaryExpanded-26 MuiIconButton-edgeEnd"
aria-disabled="false" aria-hidden="true"><span class="MuiIconButton-label"><svg
class="MuiSvgIcon-root makeStyles-accordionSummaryExpandedIcon-27" focusable="false"
viewBox="0 0 24 24" aria-hidden="true">
<path d="M16.59 8.59L12 13.17 7.41 8.59 6 10l6 6 6-6z"></path>
</svg></span><span class="MuiTouchRipple-root"></span></div>
</div>
<div class="MuiCollapse-root MuiCollapse-entered" style="min-height: 0px; margin-top: 30px;">
<div class="MuiCollapse-wrapper">
<div class="MuiCollapse-wrapperInner">
<div aria-labelledby="panel1bh-header" id="panel1bh-content" role="region">
<div class="MuiAccordionDetails-root">
<div class="MuiGrid-root makeStyles-searchContainer-103 MuiGrid-container">
<div class="MuiPaper-root makeStyles-paperSearch-104 MuiPaper-elevation0 MuiPaper-rounded">
<div class="MuiFormControl-root MuiTextField-root makeStyles-searchField-105"><label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined"
data-shrink="false">Search Provider by NPI</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" name="healthCareProviderInformation.searchProvider"
type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>Search Provider by
NPI</span></legend>
</fieldset>
</div>
</div>
</div>
</div>
<div class="makeStyles-spacerSmall-92"></div>
<div class="MuiGrid-root makeStyles-gridContainer-101 MuiGrid-container">
<div class="MuiGrid-root makeStyles-gridItem-102 MuiGrid-item">
<div class="MuiPaper-root makeStyles-paperRoot-94 MuiPaper-elevation0 MuiPaper-rounded">
<div
class="MuiFormControl-root MuiTextField-root makeStyles-textField-87 MuiFormControl-fullWidth">
<label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined"
data-shrink="false">Prescriber First Name</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" name="healthCareProviderInformation.prescriberFirstName"
type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>Prescriber First
Name</span></legend>
</fieldset>
</div>
</div>
<div class="makeStyles-spacerSmall-92"></div>
<div
class="MuiFormControl-root MuiTextField-root makeStyles-textField-87 MuiFormControl-fullWidth">
<label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined"
data-shrink="false">Prescriber Middle Name</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" name="healthCareProviderInformation.prescriberMiddleName"
type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>Prescriber Middle
Name</span></legend>
</fieldset>
</div>
</div>
<div class="makeStyles-spacerSmall-92"></div>
<div
class="MuiFormControl-root MuiTextField-root makeStyles-textField-87 MuiFormControl-fullWidth">
<label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined"
data-shrink="false">Prescriber Last Name</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" name="healthCareProviderInformation.prescriberLastName"
type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>Prescriber Last
Name</span></legend>
</fieldset>
</div>
</div>
<div class="makeStyles-spacerSmall-92"></div>
<div
class="MuiFormControl-root MuiTextField-root makeStyles-textField-87 MuiFormControl-fullWidth">
<label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined"
data-shrink="false">Prescriber Phone Number</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" name="healthCareProviderInformation.prescriberPhoneNumber"
type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>Prescriber Phone
Number</span></legend>
</fieldset>
</div>
</div>
<div class="makeStyles-spacerSmall-92"></div>
<div
class="MuiFormControl-root MuiTextField-root makeStyles-textField-87 MuiFormControl-fullWidth">
<label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined"
data-shrink="false">Prescriber Email</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" name="healthCareProviderInformation.prescriberEmail"
type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>Prescriber
Email</span></legend>
</fieldset>
</div>
</div>
</div>
<div class="makeStyles-spacerSmall-92"></div>
</div>
<div class="MuiGrid-root MuiGrid-item">
<div class="MuiPaper-root makeStyles-paperRoot-94 MuiPaper-elevation0 MuiPaper-rounded">
<div
class="MuiFormControl-root MuiTextField-root makeStyles-textField-87 MuiFormControl-fullWidth">
<label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined"
data-shrink="false">Address Line 1</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" name="healthCareProviderInformation.address1" type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>Address Line
1</span></legend>
</fieldset>
</div>
</div>
<div class="makeStyles-spacerSmall-92"></div>
<div
class="MuiFormControl-root MuiTextField-root makeStyles-textField-87 MuiFormControl-fullWidth">
<label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined"
data-shrink="false">Address Line 2</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" name="healthCareProviderInformation.address2" type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>Address Line
2</span></legend>
</fieldset>
</div>
</div>
<div class="makeStyles-spacerSmall-92"></div>
<div
class="MuiFormControl-root MuiTextField-root makeStyles-textField-87 MuiFormControl-fullWidth">
<label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined"
data-shrink="false">City</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" name="healthCareProviderInformation.city" type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>City</span></legend>
</fieldset>
</div>
</div>
<div class="makeStyles-spacerSmall-92"></div>
<div class="MuiFormControl-root"><label
class="fevi_label MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-outlined"
data-shrink="false" id="demo-simple-select-outlined-label">State</label>
<div class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-formControl height-40">
<select
class="MuiSelect-root MuiSelect-select MuiSelect-outlined MuiInputBase-input MuiOutlinedInput-input"
aria-invalid="false" id="patientInfoSelect" name="patientInformation.state">
<option value=""></option>
<option value="ohio">Ohio</option>
<option value="california">California</option>
<option value="New York">New York</option>
<option value="Texas">Texas</option>
<option value="Utah">Utah</option>
</select><svg class="MuiSvgIcon-root MuiSelect-icon MuiSelect-iconOutlined"
focusable="false" viewBox="0 0 24 24" aria-hidden="true">
<path d="M7 10l5 5 5-5z"></path>
</svg>
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>State</span>
</legend>
</fieldset>
</div>
</div>
<div class="makeStyles-spacerSmall-92"></div>
<div
class="MuiFormControl-root MuiTextField-root makeStyles-textField-87 MuiFormControl-fullWidth">
<label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined"
data-shrink="false">Zip Code</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" name="healthCareProviderInformation.zipCode" type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>Zip Code</span>
</legend>
</fieldset>
</div>
</div>
</div>
</div>
<div class="MuiGrid-root MuiGrid-item">
<div class="MuiPaper-root makeStyles-paperRoot-94 MuiPaper-elevation0 MuiPaper-rounded">
<div
class="MuiFormControl-root MuiTextField-root makeStyles-textField-87 MuiFormControl-fullWidth">
<label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined"
data-shrink="false">Contact Person Name</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" name="healthCareProviderInformation.contactPersonName"
type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>Contact Person
Name</span></legend>
</fieldset>
</div>
</div>
<div class="makeStyles-spacerSmall-92"></div>
<div
class="MuiFormControl-root MuiTextField-root makeStyles-textField-87 MuiFormControl-fullWidth">
<label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined"
data-shrink="false">Contact Person Phone Number</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false"
name="healthCareProviderInformation.contactPersonPhoneNumber" type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>Contact Person Phone
Number</span></legend>
</fieldset>
</div>
</div>
<div class="makeStyles-spacerSmall-92"></div>
<div
class="MuiFormControl-root MuiTextField-root makeStyles-textField-87 MuiFormControl-fullWidth">
<label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined"
data-shrink="false">Contact Person Email</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" name="healthCareProviderInformation.contactPersonEmail"
type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>Contact Person
Email</span></legend>
</fieldset>
</div>
</div>
<div class="makeStyles-spacerSmall-92"></div>
<div
class="MuiFormControl-root MuiTextField-root makeStyles-textField-87 MuiFormControl-fullWidth">
<label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined"
data-shrink="false">Fax Number</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" name="healthCareProviderInformation.faxNumber" type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>Fax Number</span>
</legend>
</fieldset>
</div>
</div>
<div class="makeStyles-spacerSmall-92"></div>
</div>
</div>
</div>
<p class="MuiTypography-root MuiTypography-body1 signing_text"><i
style="color: rgb(0, 0, 0); font-size: 0.9rem;">By signing below, I certify that the
therapy described above is medically necessary and that the information provided is
accurate to the best of my knowledge. I also attest that i have obtained the patient's
authorization to release the above information and such other personal information as may
be necessay to PROLASTIN DIRECT, EVERSANA, and/or the their agents. If the patient is 18
year old or younger, I attest that I have obtained permission from the patient's legal
guardian.</i></p>
<div class="MuiGrid-root makeStyles-cosentCotainer-108 MuiGrid-container">
<div class="MuiGrid-root makeStyles-signPadRoot-106 MuiGrid-item">
<!-- <div><span class="makeStyles-signPadPlaceHolder-107">Click here to sign</span></div>
-->
<div class="makeStyles-spacer-90"></div>
<div class="makeStyles-spacer-90"></div>
<div class="makeStyles-paperItem-61-3 MuiPaper-elevation0 MuiPaper-rounded">
<div class="MuiFormGroup-root allergies_group">
<label class="MuiFormControlLabel-root">
<span class="MuiButtonBase-root MuiIconButton-root PrivateSwitchBase-root-49 MuiCheckbox-root MuiCheckbox-colorPrimary MuiIconButton-colorPrimary" aria-disabled="false"><span class="MuiIconButton-label"><input class="PrivateSwitchBase-input-52" name="medicalInformation.allergies.none" type="checkbox" data-indeterminate="false" value=""><svg class="MuiSvgIcon-root" focusable="false" viewBox="0 0 24 24" aria-hidden="true">
<path d="M19 5v14H5V5h14m0-2H5c-1.1 0-2 .9-2 2v14c0 1.1.9 2 2 2h14c1.1 0 2-.9 2-2V5c0-1.1-.9-2-2-2z">
</path>
</svg></span><span class="MuiTouchRipple-root"></span></span><span class="MuiTypography-root MuiFormControlLabel-label MuiTypography-body1">Substitution Permitted</span></label><label class="MuiFormControlLabel-root"><span class="MuiButtonBase-root MuiIconButton-root PrivateSwitchBase-root-49 MuiCheckbox-root MuiCheckbox-colorPrimary MuiIconButton-colorPrimary" aria-disabled="false"><span class="MuiIconButton-label"><input class="PrivateSwitchBase-input-52 specify_checkbox" name="medicalInformation.allergies.specify" type="checkbox" data-indeterminate="false" value=""><svg class="MuiSvgIcon-root" focusable="false" viewBox="0 0 24 24" aria-hidden="true">
<path d="M19 5v14H5V5h14m0-2H5c-1.1 0-2 .9-2 2v14c0 1.1.9 2 2 2h14c1.1 0 2-.9 2-2V5c0-1.1-.9-2-2-2z">
</path>
</svg></span><span class="MuiTouchRipple-root"></span></span><span class="MuiTypography-root MuiFormControlLabel-label MuiTypography-body1">Dispense as Written</span></label>
<div class="MuiFormControl-root MuiTextField-root makeStyles-textField-62 specify_field" style="display: none;"><label class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-marginDense MuiInputLabel-outlined" data-shrink="false">Specific</label>
<div class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" name="medicalInformation.allergies.specify" type="text" class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense" value="">
<fieldset aria-hidden="true" class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend class="PrivateNotchedOutline-legendLabelled-47"><span>Specific</span>
</legend>
</fieldset>
</div>
</div>
<div class="signature_div">
<div class="mb-1"><span class="makeStyles-signPadPlaceHolder-107">Click here to sign</span></div>
<p class="MuiTypography-root makeStyles-caption-98 MuiTypography-body1 text-center">Physician Signature</p>
</div>
<!--<p class="MuiTypography-root makeStyles-caption-98 MuiTypography-body1">Physician Signature</p>-->
</div>
</div>
</div>
<div class="MuiGrid-root MuiGrid-item" style="padding-right: 22px;">
<!--<div class="mb-3"><span class="makeStyles-signPadPlaceHolder-107">Click here to sign</span></div>-->
<div class="MuiPaper-root MuiPaper-elevation0 MuiPaper-rounded"
style="width: 280px; background-color: transparent;">
<div class="makeStyles-spacer-90"></div>
<div class="makeStyles-spacer-90"></div>
<div class="MuiFormControl-root MuiTextField-root MuiFormControl-fullWidth"><label
class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated MuiInputLabel-shrink MuiInputLabel-marginDense MuiInputLabel-outlined "
data-shrink="true">Date</label>
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="true" name="physicianInformation.Date" type="Date"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline">
<legend
class="PrivateNotchedOutline-legendLabelled-47 PrivateNotchedOutline-legendNotched-48">
<span>Date</span>
</legend>
</fieldset>
</div>
</div>
</div>
</div>
</div>
<div class="makeStyles-spacer-17"></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="makeStyles-spacerMedium-18"></div>
<div
class="MuiPaper-root MuiAccordion-root makeStyles-accordionRoot-24 Mui-expanded MuiAccordion-rounded MuiPaper-elevation0 MuiPaper-rounded">
<div
class="MuiButtonBase-root MuiAccordionSummary-root makeStyles-accordionSummaryRoot-25 Mui-expanded makeStyles-accordionSummaryExpanded-26"
tabindex="0" role="button" aria-disabled="false" aria-expanded="true" aria-controls="panel1bh-content"
id="panel1bh-header">
<div
class="MuiAccordionSummary-content makeStyles-accordionSummaryContent-28 Mui-expanded makeStyles-accordionSummaryExpanded-26">
<p class="MuiTypography-root makeStyles-heading-22 MuiTypography-body1">Documentation Checklist</p>
</div>
<div
class="MuiButtonBase-root MuiIconButton-root MuiAccordionSummary-expandIcon Mui-expanded makeStyles-accordionSummaryExpanded-26 MuiIconButton-edgeEnd"
aria-disabled="false" aria-hidden="true"><span class="MuiIconButton-label"><svg
class="MuiSvgIcon-root makeStyles-accordionSummaryExpandedIcon-27" focusable="false"
viewBox="0 0 24 24" aria-hidden="true">
<path d="M16.59 8.59L12 13.17 7.41 8.59 6 10l6 6 6-6z"></path>
</svg></span><span class="MuiTouchRipple-root"></span></div>
</div>
<div class="MuiCollapse-root MuiCollapse-entered" style="min-height: 0px; margin-top: 10px;">
<div class="MuiCollapse-wrapper">
<div class="MuiCollapse-wrapperInner">
<div aria-labelledby="panel1bh-header" id="panel1bh-content" role="region">
<div class="MuiAccordionDetails-root">
<div class="MuiGrid-root MuiGrid-container MuiGrid-direction-xs-column MuiGrid-wrap-xs-nowrap">
<div class="MuiPaper-root makeStyles-paperRootInfo-118 MuiPaper-elevation0 MuiPaper-rounded checklist_block">
<h6 class="MuiTypography-root MuiTypography-subtitle1">Attach documentation of the following medical information or fax the following documentation to the PROLASTIN DIRECT team at 1-866-588-6940.</h6>
<div class="makeStyles-spacerSmall-115"></div>
<p class="MuiTypography-root MuiTypography-body1">
<!-- <div class="MuiFormControl-root MuiTextField-root makeStyles-textField-110">
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" name="document.enrollmentForm"
placeholder="1.Completed PROLASTIN-C LIQUID Prescription and Enrollment From/SMN"
type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline"
style="padding-left: 8px;">
<legend class="PrivateNotchedOutline-legend-46" style="width: 0.01px;">
<span>​</span>
</legend>
</fieldset>
</div>
</div><button color="primary" class="sc-flMoUE hjcAQm">Upload File</button>
<div></div>
<div class="makeStyles-spacerExtraSmall-116"></div>-->
<div
class="MuiFormControl-root MuiTextField-root makeStyles-textField-110 MuiFormControl-fullWidth">
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" name="document.insuranceCards"
placeholder="1.Front and back copy of patient's insurance cards" type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline"
style="padding-left: 8px;">
<legend class="PrivateNotchedOutline-legend-46" style="width: 0.01px;">
<span>​</span>
</legend>
</fieldset>
</div>
</div><button color="primary" class="sc-flMoUE hjcAQm">Upload File</button>
<div class="makeStyles-spacerExtraSmall-116"></div>
<div
class="MuiFormControl-root MuiTextField-root makeStyles-textField-110 MuiFormControl-fullWidth">
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" name="document.historySummary"
placeholder="2.History/Physical Summary" type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline"
style="padding-left: 8px;">
<legend class="PrivateNotchedOutline-legend-46" style="width: 0.01px;">
<span>​</span>
</legend>
</fieldset>
</div>
</div><button color="primary" class="sc-flMoUE hjcAQm">Upload File</button>
<div class="makeStyles-spacerExtraSmall-116"></div>
<div
class="MuiFormControl-root MuiTextField-root makeStyles-textField-110 MuiFormControl-fullWidth">
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" name="document.xRayDiagnostic"
placeholder="3.Last Chest X-ray diagnostic report" type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline"
style="padding-left: 8px;">
<legend class="PrivateNotchedOutline-legend-46" style="width: 0.01px;">
<span>​</span>
</legend>
</fieldset>
</div>
</div><button color="primary" class="sc-flMoUE hjcAQm">Upload File</button>
<div class="makeStyles-spacerExtraSmall-116"></div>
<div
class="MuiFormControl-root MuiTextField-root makeStyles-textField-110 MuiFormControl-fullWidth">
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" name="document.historySummary"
placeholder="4.Most recent Pulmonary Function Report including FEV1" type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline"
style="padding-left: 8px;">
<legend class="PrivateNotchedOutline-legend-46" style="width: 0.01px;">
<span>​</span>
</legend>
</fieldset>
</div>
</div><button color="primary" class="sc-flMoUE hjcAQm">Upload File</button>
<div class="makeStyles-spacerExtraSmall-116"></div>
<div
class="MuiFormControl-root MuiTextField-root makeStyles-textField-110 MuiFormControl-fullWidth">
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" name="document.aatReports.aatLevel"
placeholder="5.a) AAT Lab Reports: Serum AAT Level" type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline"
style="padding-left: 8px;">
<legend class="PrivateNotchedOutline-legend-46" style="width: 0.01px;">
<span>​</span>
</legend>
</fieldset>
</div>
</div><button color="primary" class="sc-flMoUE hjcAQm">Upload File</button>
<div class="makeStyles-spacerExtraSmall-116"></div>
<div
class="MuiFormControl-root MuiTextField-root makeStyles-textField-110 MuiFormControl-fullWidth">
<div
class="MuiInputBase-root MuiOutlinedInput-root MuiInputBase-fullWidth MuiInputBase-formControl MuiInputBase-marginDense MuiOutlinedInput-marginDense">
<input aria-invalid="false" name="document.aatPhenotype"
placeholder="5.b) AAT Phenotype or Genotype*" type="text"
class="MuiInputBase-input MuiOutlinedInput-input MuiInputBase-inputMarginDense MuiOutlinedInput-inputMarginDense"
value="">
<fieldset aria-hidden="true"
class="PrivateNotchedOutline-root-45 MuiOutlinedInput-notchedOutline"
style="padding-left: 8px;">
<legend class="PrivateNotchedOutline-legend-46" style="width: 0.01px;">
<span>​</span>
</legend>
</fieldset>
</div>
</div><button color="primary" class="sc-flMoUE hjcAQm">Upload File</button>
<div class="makeStyles-spacerExtraSmall-116"></div>
</p>
</div>
</div>
<div class="makeStyles-spacer-17"></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="makeStyles-spacerMedium-18"></div>
<div
class="MuiPaper-root MuiAccordion-root makeStyles-accordionRoot-24 Mui-expanded MuiAccordion-rounded MuiPaper-elevation0 MuiPaper-rounded">
<div
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<p class="MuiTypography-root makeStyles-heading-22 MuiTypography-body1">Steps to e-Prescribe PROLASTIN-C LIQUID</p>
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<!--<h6 class="MuiTypography-root MuiTypography-h6">Steps to e-Prescribe PROLASTIN-C LIQUID</h6>-->
<p class="MuiTypography-root MuiTypography-body1">
1. Fill in the PROLASTIN-C LIQUID Prescription and Enrollment Form/SMN <br>
2. Prescribe PROLASTIN-C LIQUID Intravenous Solution <br>
3. Choose EVERSANA as the dispensing pharmacy <br>
*EVERSANA is the exclusive dispensing pharmacy for PROLASTIN-C LIQUID
</p>
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<p class="MuiTypography-root makeStyles-heading-22 MuiTypography-body1">Important Safety Information
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<!--<h6 class="MuiTypography-root MuiTypography-h6">Important Safety Information</h6>-->
<p class="MuiTypography-root MuiTypography-body1">PROLASTIN®-C LIQUID is an
alpha1-proteinase inhibitor (human) (alpha1-PI) indicated for chronic augmentation and
maintenance therapy in adults with clinical evidence of emphysema due to severe
hereditary deficiency of alpha1-PI (alpha1-antitrypsin deficiency).</p>
<div class="makeStyles-spacerSmall-129"></div>
<h6 class="MuiTypography-root MuiTypography-h6" style="text-decoration: underline;">
Limitations of Use</h6>
<div class="makeStyles-spacerSmall-129"></div>
<ul>
<li>The effect of augmentation therapy with any alpha1-PI, including PROLASTIN-C LIQUID,
on pulmonary exacerbations and on the progression of emphysema in alpha1-PI deficiency
has not been conclusively demonstrated in randomized, controlled clinical trials</li>
<div class="makeStyles-spacerExtraSmall-130"></div>
<li>Clinical data demonstrating the long-term effects of chronic augmentation or
maintenance therapy with PROLASTIN-C LIQUID are not available</li>
<div class="makeStyles-spacerExtraSmall-130"></div>
<li>PROLASTIN-C LIQUID is not indicated as therapy for lung disease in patients in whom
severe alpha1-PI deficiency has not been established</li>
</ul>
<p class="MuiTypography-root MuiTypography-body1">PROLASTIN-C LIQUID is contraindicated in
immunoglobulin A (IgA)-deficient patients with antibodies against IgA or patients with a
history of anaphylaxis or other severe systemic reaction to alpha1-PI products.</p>
<div class="makeStyles-spacerExtraSmall-130"></div>
<p class="MuiTypography-root MuiTypography-body1">Hypersensitivity reactions, including
anaphylaxis, may occur. Monitor vital signs and observe the patient carefully throughout
the infusion. If hypersensitivity symptoms occur, promptly stop PROLASTIN-C LIQUID
infusion and begin appropriate therapy.</p>
<div class="makeStyles-spacerExtraSmall-130"></div>
<p class="MuiTypography-root MuiTypography-body1">Because PROLASTIN-C LIQUID is made from
human plasma, it may carry a risk of transmitting infectious agents, eg, viruses, the
variant Creutzfeldt-Jakob disease (vCJD) agent, and, theoretically, the
Creutzfeldt-Jakob disease (CJD) agent. This also applies to unknown or emerging viruses
and other pathogens.</p>
<div class="makeStyles-spacerExtraSmall-130"></div>
<p class="MuiTypography-root MuiTypography-body1">The most common adverse reactions during
PROLASTIN-C LIQUID clinical trials in greater than 5% of subjects were diarrhea and
fatigue, each of which occurred in 2 subjects (6%).</p>
<div class="makeStyles-spacerSmall-129"></div>
<h6 class="MuiTypography-root MuiTypography-h6">Please see accompanying full Prescribing
Information for PROLASTIN-C LIQUID.</h6>
</div>
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Grifols</span><span style="margin-right: 20px;">All rights reserved</span><span
style="margin-right: 20px;">Revised September 2021</span><span
style="margin-right: 20px;">RD-5-01c</span><span
style="margin-right: 20px;">US-PRL-2000163</span></div>
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