{"id":390,"date":"2022-02-24T18:19:40","date_gmt":"2022-02-24T18:19:40","guid":{"rendered":"https:\/\/www.workerschoicerx.com\/?page_id=390"},"modified":"2022-09-22T13:55:49","modified_gmt":"2022-09-22T13:55:49","slug":"forms","status":"publish","type":"page","link":"https:\/\/www.workerschoicerx.com\/index.php\/forms\/","title":{"rendered":"Forms"},"content":{"rendered":"<p><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#eae9e9;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"max-width:1352px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-text fusion-text-1\"><h1 style=\"text-align: center;\">Patient Forms Download<\/h1>\n<p style=\"text-align: center;\">\u00a0<\/p>\n<\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-0{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-0 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-0{width:100% !important;}.fusion-builder-column-0 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-0{width:100% !important;}.fusion-builder-column-0 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 183px 0px 183px;\"><div class=\"fusion-content-boxes content-boxes columns row fusion-columns-1 fusion-columns-total-3 fusion-content-boxes-1 content-boxes-icon-with-title content-left\" data-animationOffset=\"top-into-view\" style=\"margin-top:0px;margin-bottom:0px;\"><style type=\"text\/css\">.fusion-content-boxes-1 .heading .content-box-heading {color:#333333;}\n\t\t\t\t\t.fusion-content-boxes-1 .fusion-content-box-hover .link-area-link-icon-hover .heading .content-box-heading,\n\t\t\t\t\t.fusion-content-boxes-1 .fusion-content-box-hover .link-area-link-icon-hover .heading .heading-link .content-box-heading,\n\t\t\t\t\t.fusion-content-boxes-1 .fusion-content-box-hover .link-area-box-hover .heading .content-box-heading,\n\t\t\t\t\t.fusion-content-boxes-1 .fusion-content-box-hover .link-area-box-hover .heading .heading-link .content-box-heading,\n\t\t\t\t\t.fusion-content-boxes-1 .fusion-content-box-hover .link-area-link-icon-hover.link-area-box .fusion-read-more,\n\t\t\t\t\t.fusion-content-boxes-1 .fusion-content-box-hover .link-area-link-icon-hover.link-area-box .fusion-read-more::after,\n\t\t\t\t\t.fusion-content-boxes-1 .fusion-content-box-hover .link-area-link-icon-hover.link-area-box .fusion-read-more::before,\n\t\t\t\t\t.fusion-content-boxes-1 .fusion-content-box-hover .fusion-read-more:hover:after,\n\t\t\t\t\t.fusion-content-boxes-1 .fusion-content-box-hover .fusion-read-more:hover:before,\n\t\t\t\t\t.fusion-content-boxes-1 .fusion-content-box-hover .fusion-read-more:hover,\n\t\t\t\t\t.fusion-content-boxes-1 .fusion-content-box-hover .link-area-box-hover.link-area-box .fusion-read-more,\n\t\t\t\t\t.fusion-content-boxes-1 .fusion-content-box-hover .link-area-box-hover.link-area-box .fusion-read-more::after,\n\t\t\t\t\t.fusion-content-boxes-1 .fusion-content-box-hover .link-area-box-hover.link-area-box .fusion-read-more::before,\n\t\t\t\t\t.fusion-content-boxes-1 .fusion-content-box-hover .link-area-link-icon-hover .icon .circle-no,\n\t\t\t\t\t.fusion-content-boxes-1 .heading .heading-link:hover .content-box-heading {\n\t\t\t\t\t\tcolor: #005c96;\n\t\t\t\t\t}\n\t\t\t\t\t.fusion-content-boxes-1 .fusion-content-box-hover .link-area-box-hover .icon .circle-no {\n\t\t\t\t\t\tcolor: #005c96 !important;\n\t\t\t\t\t}.fusion-content-boxes-1 .fusion-content-box-hover .link-area-box.link-area-box-hover .fusion-content-box-button {background: rgba(0,0,0,0.24);color: #ffffff;}.fusion-content-boxes-1 .fusion-content-box-hover .link-area-box.link-area-box-hover .fusion-content-box-button .fusion-button-text {color: #ffffff;}\n\t\t\t\t\t.fusion-content-boxes-1 .fusion-content-box-hover .link-area-link-icon-hover .heading .icon > span {\n\t\t\t\t\t\tbackground-color: #005c96 !important;\n\t\t\t\t\t}\n\t\t\t\t\t.fusion-content-boxes-1 .fusion-content-box-hover .link-area-box-hover .heading .icon > span {\n\t\t\t\t\t\tborder-color: #005c96 !important;\n\t\t\t\t\t}<\/style><div class=\"fusion-column content-box-column content-box-column content-box-column-1 col-lg-12 col-md-12 col-sm-12 fusion-content-box-hover content-box-column-last-in-row\"><div class=\"col content-box-wrapper content-wrapper link-area-link-icon link-type-button-bar icon-hover-animation-fade\" style=\"background-color:rgba(255,255,255,0);\" data-animationOffset=\"top-into-view\"><div class=\"heading heading-with-icon icon-left\"><a class=\"heading-link\" style=\"float:left;\" href=\"https:\/\/www.workerschoicerx.com\/wp-content\/uploads\/2022\/02\/Workers-Choice-Autofill-Program-Form.pdf\" target=\"_self\"><div class=\"icon\"><i style=\"border-color:#333333;border-width:1px;background-color:#333333;box-sizing:content-box;height:62px;width:62px;line-height:62px;border-radius:50%;color:#ffffff;font-size:31px;\" aria-hidden=\"true\" class=\"fontawesome-icon fa-book fas circle-yes\"><\/i><\/div><h2 class=\"content-box-heading\" style=\"font-size:31px;line-height:36px;\">Workers' Choice Autofill Program Enrollment Form<\/h2><\/a><\/div><div class=\"fusion-clearfix\"><\/div><div class=\"content-container\" style=\"color:#747474;\">\n<h3>At Worker\u2019s Choice we know just how busy life can be, and to help you maintain your treatment and stay pain free, we offer an automatic refill program.\u00a0 Qualifying prescriptions will be sent to you automatically as soon as your medication is available for refill.\u00a0 When your last prescribed refill is coming up, we can work with your physician to help get it renewed.<\/h3>\n<h3>Enrollment into the Peace of Mind Automatic Refill Program is free and easy!\u00a0 Simply complete the information below and return to Workers\u2019 Choice to get started. \u00a0If you have any questions about the program, please call the pharmacy at (855) 969-3443.\u00a0 We appreciate your business and wish you Peace of Mind!<\/h3>\n<\/div><div class=\"fusion-clearfix\"><\/div><a class=\" fusion-read-more fusion-button-bar\" style=\"float:left;\" href=\"https:\/\/www.workerschoicerx.com\/wp-content\/uploads\/2022\/02\/Workers-Choice-Autofill-Program-Form.pdf\" target=\"_self\">Download Autofill Program Form<\/a><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-column content-box-column content-box-column content-box-column-2 col-lg-12 col-md-12 col-sm-12 fusion-content-box-hover content-box-column-last-in-row\"><div class=\"col content-box-wrapper content-wrapper link-area-link-icon link-type-button-bar icon-hover-animation-fade\" style=\"background-color:rgba(255,255,255,0);\" data-animationOffset=\"top-into-view\"><div class=\"heading heading-with-icon icon-left\"><a class=\"heading-link\" style=\"float:left;\" href=\"https:\/\/www.workerschoicerx.com\/wp-content\/uploads\/2022\/02\/Workers-Choice-Patient-Acknowledgement-Form.pdf\" target=\"_self\"><div class=\"icon\"><i style=\"border-color:#333333;border-width:1px;background-color:#333333;box-sizing:content-box;height:62px;width:62px;line-height:62px;border-radius:50%;color:#ffffff;font-size:31px;\" aria-hidden=\"true\" class=\"fontawesome-icon fa-book fas circle-yes\"><\/i><\/div><h2 class=\"content-box-heading\" style=\"font-size:31px;line-height:36px;\">Workers' Choice Patient Acknowledgement Form<\/h2><\/a><\/div><div class=\"fusion-clearfix\"><\/div><div class=\"content-container\" style=\"color:#747474;\">\n<h3>Effective May 1, 2013, the new federal law known as the <strong>Health Insurance Portability and Accountability Act<\/strong> of 1996 (\u201cHIPAA\u201d) requires that this pharmacy comply with certain rules and regarding the maintenance of the privacy of your information that we have collected and will collect in the future.<\/h3>\n<h3>To comply with one of HIPAA\u2019s requirements, we are offering you a copy of our Notice of Privacy Practices.\u00a0 This <strong>Notice of Privacy Practices<\/strong> contains the necessary information that HIPAA requires us to disclose regarding our privacy practices.<\/h3>\n<\/div><div class=\"fusion-clearfix\"><\/div><a class=\" fusion-read-more fusion-button-bar\" style=\"float:left;\" href=\"https:\/\/www.workerschoicerx.com\/wp-content\/uploads\/2022\/02\/Workers-Choice-Patient-Acknowledgement-Form.pdf\" target=\"_self\">Download Patient Acknowledgement Form<\/a><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-column content-box-column content-box-column content-box-column-3 col-lg-12 col-md-12 col-sm-12 fusion-content-box-hover content-box-column-last content-box-column-last-in-row\"><div class=\"col content-box-wrapper content-wrapper link-area-link-icon link-type-button-bar icon-hover-animation-fade\" style=\"background-color:rgba(255,255,255,0);\" data-animationOffset=\"top-into-view\"><div class=\"heading heading-with-icon icon-left\"><a class=\"heading-link\" style=\"float:left;\" href=\"https:\/\/www.workerschoicerx.com\/wp-content\/uploads\/2022\/02\/Workers-Choice-HIPAA-Privacy-Practices.pdf\" target=\"_self\"><div class=\"icon\"><i style=\"border-color:#333333;border-width:1px;background-color:#333333;box-sizing:content-box;height:62px;width:62px;line-height:62px;border-radius:50%;color:#ffffff;font-size:31px;\" aria-hidden=\"true\" class=\"fontawesome-icon fa-book fas circle-yes\"><\/i><\/div><h2 class=\"content-box-heading\" style=\"font-size:31px;line-height:36px;\">Workers' Choice HIPAA Privacy Practices<\/h2><\/a><\/div><div class=\"fusion-clearfix\"><\/div><div class=\"content-container\" style=\"color:#747474;\">\n<h3>The Pharmacy is required by law to maintain the privacy of the health information it maintains about its customers (also known as \u201c<strong>Protected Health Information<\/strong>\u201d or \u201c<strong>PHI<\/strong>\u201d) and to provide its customers with notice of our legal duties and privacy practices with respect to PHI. PHI is information that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. This Notice of Privacy Practices (\u201c<strong>Notice<\/strong>\u201d) describes how we may use and disclose PHI to carry out treatment, obtain payment or perform our health care operations and for other specified purposes that are permitted or required by law. This Notice also describes your rights with respect to PHI about you.<\/h3>\n<\/div><div class=\"fusion-clearfix\"><\/div><a class=\" fusion-read-more fusion-button-bar\" style=\"float:left;\" href=\"https:\/\/www.workerschoicerx.com\/wp-content\/uploads\/2022\/02\/Workers-Choice-HIPAA-Privacy-Practices.pdf\" target=\"_self\">Download Privacy Practices<\/a><div class=\"fusion-clearfix\"><\/div><\/div><\/div><style type=\"text\/css\">\n\t\t\t\t\t\t.fusion-content-boxes-1 .fusion-content-box-hover .heading-link:hover .icon i.circle-yes,\n\t\t\t\t\t\t.fusion-content-boxes-1 .fusion-content-box-hover .link-area-box:hover .heading-link .icon i.circle-yes,\n\t\t\t\t\t\t.fusion-content-boxes-1 .fusion-content-box-hover .link-area-link-icon-hover .heading .icon i.circle-yes,\n\t\t\t\t\t\t.fusion-content-boxes-1 .fusion-content-box-hover .link-area-box-hover .heading .icon i.circle-yes {\n\t\t\t\t\t\t\tbackground-color: #005c96 !important;\n\t\t\t\t\t\t\tborder-color: #005c96 !important;\n\t\t\t\t\t\t}<\/style><div class=\"fusion-clearfix\"><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-1{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-1 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 183px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 183px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-1{width:100% !important;order : 0;}.fusion-builder-column-1 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-1{width:100% !important;order : 0;}.fusion-builder-column-1 > .fusion-column-wrapper {padding-right : 0px !important;margin-right : 1.92%;padding-left : 0px !important;margin-left : 2.016%;}}<\/style><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-flex-container.fusion-builder-row-1{ padding-top : 0px;margin-top : 0px;padding-right : 0px;padding-bottom : 0px;margin-bottom : 0px;padding-left : 0px;}<\/style><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2 nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(96,125,139,0);background-position: center top;background-repeat: no-repeat;padding-top:0px;padding-right:0px;padding-bottom:15px;padding-left:0px;margin-bottom: 0px;margin-top: 0px;border-width: 0px 0px 0px 0px;border-color:#eae9e9;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_6 1_6 fusion-one-sixth fusion-column-first fusion-no-small-visibility\" style=\"width:13.3333%; margin-right: 4%;margin-top:0px;margin-bottom:20px;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-3 fusion_builder_column_2_3 2_3 fusion-two-third\" style=\"width:65.3333%; margin-right: 4%;margin-top:0px;margin-bottom:0px;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:rgba(255,255,255,0);padding: 0px 0px 0px 0px;\"><div class=\"fusion-fa-align-center\"><i class=\"fb-icon-element-1 fb-icon-element fontawesome-icon fa-envelope far circle-no\" style=\"font-size:95px;margin-top:15px;margin-bottom:15px;\"><\/i><\/div><style>i.fb-icon-element.fontawesome-icon.fb-icon-element-1{ color: #000000;}i.fb-icon-element.fontawesome-icon.fb-icon-element-1:hover { color: #000000;}<\/style><div class=\"fusion-text fusion-text-2\" style=\"color:#000000;\"><h2 style=\"color: white; text-align: center; --fontsize: 24; line-height: 1.5; --minfontsize: 24;\" data-fontsize=\"24\" data-lineheight=\"36px\" class=\"fusion-responsive-typography-calculated\"><b><span style=\"color: #000000;\">Focus on your recovery.<\/span><span style=\"color: #000000;\"><br \/>\nLet Workers\u2019 Choice take care of the hassle for you.<\/span><\/b><\/h2>\n<\/div><div class=\"fusion-text fusion-text-3\"><h1 style=\"text-align: center;\">Request a Free Consultation:<\/h1>\n<\/div><style>.fusion-form-form-wrapper .fusion-form-350 .fusion-form-tooltip .fusion-form-tooltip-content{color:#ffffff !important;background-color:#333333 !important;border-color:#333333 !important;}.fusion-form-form-wrapper .fusion-form-350 input::placeholder{color:rgba(0,0,0,0.5);}.fusion-form-form-wrapper .fusion-form-350 textarea::placeholder{color:rgba(0,0,0,0.5);}.fusion-form-form-wrapper .fusion-form-350 select:invalid{color:rgba(0,0,0,0.5);}.fusion-form-form-wrapper .fusion-form-350 .fusion-form-input-with-icon > i{color:#000000 !important;}.fusion-form-form-wrapper .fusion-form-350 input.fusion-form-upload-field::placeholder{color:#000000;}.fusion-form-form-wrapper .fusion-form-350 option,.fusion-form-form-wrapper .fusion-form-350 input[type=\"date\"]{color:#000000;}.fusion-form-form-wrapper .fusion-form-350 input[type=\"datetime-local\"]{color:#000000;}.fusion-form-form-wrapper .fusion-form-350 input[type=\"email\"]{color:#000000;}.fusion-form-form-wrapper .fusion-form-350 input[type=\"month\"]{color:#000000;}.fusion-form-form-wrapper .fusion-form-350 input[type=\"number\"]{color:#000000;}.fusion-form-form-wrapper .fusion-form-350 input[type=\"password\"]{color:#000000;}.fusion-form-form-wrapper .fusion-form-350 input[type=\"search\"]{color:#000000;}.fusion-form-form-wrapper .fusion-form-350 input[type=\"tel\"]{color:#000000;}.fusion-form-form-wrapper .fusion-form-350 input[type=\"phone-number\"]{color:#000000;}.fusion-form-form-wrapper .fusion-form-350 input[type=\"text\"]{color:#000000;}.fusion-form-form-wrapper .fusion-form-350 input[type=\"time\"]{color:#000000;}.fusion-form-form-wrapper .fusion-form-350 input[type=\"url\"]{color:#000000;}.fusion-form-form-wrapper .fusion-form-350 input[type=\"week\"]{color:#000000;}.fusion-form-form-wrapper .fusion-form-350 input[type=\"datetime\"]{color:#000000;}.fusion-form-form-wrapper .fusion-form-350 select{color:#000000;}.fusion-form-form-wrapper .fusion-form-350 textarea{color:#000000;}.fusion-form-form-wrapper .fusion-form-350 input[type=\"upload\"]{color:#000000;}.fusion-form-form-wrapper .fusion-form-350 .fusion-select-wrapper .select-arrow path{stroke:#000000 !important;}.fusion-form-form-wrapper .fusion-form-350 label, .fusion-form-form-wrapper .fusion-form-350 .label{color:#000000;}<\/style><div class=\"fusion-form fusion-form-builder fusion-form-form-wrapper fusion-form-350\" data-form-id=\"350\" data-config=\"{&quot;form_id&quot;:&quot;350&quot;,&quot;form_post_id&quot;:&quot;350&quot;,&quot;post_id&quot;:390,&quot;form_type&quot;:&quot;database_email&quot;,&quot;confirmation_type&quot;:&quot;message&quot;,&quot;redirect_url&quot;:&quot;&quot;,&quot;field_labels&quot;:{&quot;first_name&quot;:&quot;First name&quot;,&quot;email_address&quot;:&quot;Email address&quot;,&quot;last_name&quot;:&quot;Last name&quot;,&quot;phone_number&quot;:&quot;Phone number&quot;,&quot;message&quot;:&quot;Message&quot;},&quot;field_logics&quot;:{&quot;first_name&quot;:&quot;&quot;,&quot;email_address&quot;:&quot;&quot;,&quot;last_name&quot;:&quot;&quot;,&quot;phone_number&quot;:&quot;&quot;,&quot;message&quot;:&quot;&quot;}}\"><form action=\"https:\/\/www.workerschoicerx.com\/index.php\/forms\/\" method=\"post\" class=\"fusion-form fusion-form-350\"><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#eae9e9;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-4 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"350\"><div class=\"fusion-form-label-wrapper\"><label for=\"first_name\">First name <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"fa-address-card fas\"><\/i><input type=\"text\" name=\"first_name\" id=\"first_name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><div class=\"fusion-form-field fusion-form-email-field fusion-form-label-above\" data-form-id=\"350\"><div class=\"fusion-form-label-wrapper\"><label for=\"email_address\">Email address <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"fa-envelope fas\"><\/i><input type=\"email\" name=\"email_address\" id=\"email_address\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-4{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-4 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-4{width:100% !important;order : 0;}.fusion-builder-column-4 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-4{width:100% !important;order : 0;}.fusion-builder-column-4 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-5 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"350\"><div class=\"fusion-form-label-wrapper\"><label for=\"last_name\">Last name<\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"fa-address-card fas\"><\/i><input type=\"text\" name=\"last_name\" id=\"last_name\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" data-form-id=\"350\"><div class=\"fusion-form-label-wrapper\"><label for=\"phone_number\">Phone number<\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"fa-phone fas\"><\/i><input type=\"phone-number\" name=\"phone_number\" id=\"phone_number\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" pattern=\"[0-9()#&+*-=.]+\" title=\"Only numbers and phone characters are accepted.\"\/><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-5{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-5 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-5{width:100% !important;order : 0;}.fusion-builder-column-5 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-5{width:100% !important;order : 0;}.fusion-builder-column-5 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-6 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" data-form-id=\"350\"><label for=\"message\">Message<\/label><textarea cols=\"40\"  minlength=\"0\"  rows=\"4\" tabindex=\"\" id=\"message\" name=\"message\" class=\"fusion-form-input\" data-holds-private-data=\"false\"><\/textarea><\/div><div class=\"form-submission-notices\" id=\"fusion-notices-1\"><div class=\"fusion-alert alert success alert-success fusion-alert-center fusion-form-response fusion-form-response-success fusion-alert-capitalize alert-dismissable\" style=\"background-color:#dff0d8;color:#5ca340;border-color:#5ca340;border-width:1px;\"><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-label=\"Close\">&times;<\/button><div class=\"fusion-alert-content-wrapper\"><span class=\"alert-icon\"><i class=\"fa-lg fa fa-check-circle\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-alert-content\">Thank you for your message. Workers Choice RX will be in touch soon!<\/span><\/div><\/div><div class=\"fusion-alert alert error alert-danger fusion-alert-center fusion-form-response fusion-form-response-error fusion-alert-capitalize alert-dismissable\" style=\"background-color:#f2dede;color:#a64242;border-color:#a64242;border-width:1px;\"><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-label=\"Close\">&times;<\/button><div class=\"fusion-alert-content-wrapper\"><span class=\"alert-icon\"><i class=\"fa-lg fa fa-exclamation-triangle\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-alert-content\">There was an error trying to send your message. Please check the reCAPTCHA checkbox.<\/span><\/div><\/div><\/div><div class=\"fusion-form-field fusion-form-recaptcha-field fusion-form-label-above\" data-form-id=\"350\">\t\t\t\t\t\t\t\t\t<div class=\"form-creator-recaptcha\" >\n\t\t\t\t\t\t\t\t\t\t\t\t\t<div\n\t\t\t\t\t\t\t\tid=\"g-recaptcha-350-1\"\n\t\t\t\t\t\t\t\tclass=\"fusion-form-recaptcha-v2\"\n\t\t\t\t\t\t\t\tdata-theme=\"light\"\n\t\t\t\t\t\t\t\tdata-sitekey=\"6LdS3qseAAAAACNkJdDyhDYM72D0PnrNd7lbpJix\"\n\t\t\t\t\t\t\t\tdata-tabindex=\"\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div><div class=\"fusion-form-field fusion-form-submit-field fusion-form-label-above\" data-form-id=\"350\"><div style=\"text-align:left;\"><style>.fusion-button.button-1{border-radius:2px 2px 2px 2px;}<\/style><button type=\"submit\" class=\"fusion-button button-flat fusion-button-default-size button-default button-1 fusion-button-default-span  form-form-submit button-default\" data-form-number=\"350\" 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