.IllnessForm_wrapper__LHsiR{background:#9e8aff;padding-top:1.5rem;padding-bottom:1.5rem;margin-top:1.5rem}.IllnessForm_form__dniEO{width:100%;margin-left:auto;margin-right:auto;margin-bottom:1.5rem}.IllnessForm_form__dniEO *{font-family:inherit;font-size:inherit}.IllnessForm_form__dniEO label{display:block;width:100%;margin-bottom:.5rem}.IllnessForm_form__dniEO label em{color:red}.IllnessForm_form__dniEO input[type=text],.IllnessForm_form__dniEO textarea{margin-bottom:1.5rem;padding:.25rem .5rem .5rem;border:0;outline:0;width:100%;border-radius:5px}.IllnessForm_form__dniEO select{width:100%;-webkit-appearance:none;-moz-appearance:none;appearance:none;padding:.25rem .5rem .5rem;border-radius:5px;border:0;outline:0;cursor:pointer}.IllnessForm_form__dniEO p{margin-bottom:1.5rem}.IllnessForm_form__dniEO button{background:#fff;padding:.3rem .5rem .5rem;color:#ba301c;font-size:21px;font-family:Quasimoda-SemiBold;text-align:center;border-radius:5px;-webkit-transition:all .3s ease;transition:all .3s ease;cursor:pointer;border:0}@media screen and (pointer:fine){.IllnessForm_form__dniEO button:hover{-webkit-transform:scale(1.02);transform:scale(1.02)}}.IllnessForm_selectWrapper__6aXsc{width:100%;margin-bottom:1.5rem;position:relative}.IllnessForm_arrow__KVpyn{position:absolute;right:1rem;top:50%;width:11px;height:7px;margin-top:-2px;pointer-events:none}.IllnessForm_arrow__KVpyn path{stroke:#ba301c}.IllnessForm_checkboxWrapper__nl2ki{position:relative;display:-ms-flexbox;display:flex;-ms-flex-align:center;align-items:center}.IllnessForm_checkboxWrapper__nl2ki input,.IllnessForm_checkboxWrapper__nl2ki label{width:auto;display:inline-block}.IllnessForm_checkboxWrapper__nl2ki input{margin:0 .3em .1em 0}.IllnessForm_requiredNotice__uq6_c{width:95.8333333333%;margin-left:auto;margin-right:auto}.IllnessForm_requiredNotice__uq6_c em{color:red}.IllnessForm_message__cF_no{color:#fff;border-radius:5px;padding:1rem;margin-bottom:1.5rem}.IllnessForm_message__cF_no.IllnessForm_success__VwVDw{background:#a6ad1c}.IllnessForm_message__cF_no.IllnessForm_error__DJBST{background:#ba301c}.IllnessForm_captchaMessage__P_t_y{margin-bottom:1rem}.IllnessForm_captchaSelection__TS59b{border:1px solid #fff;border-radius:5px;padding:1rem;margin-bottom:1rem}.IllnessForm_captchaSelection__TS59b input{margin:0;opacity:0;cursor:pointer;position:absolute;top:50%;left:50%}.IllnessForm_captchaSelection__TS59b label{opacity:.5;cursor:pointer;width:auto}.IllnessForm_captchaSelection__TS59b input:checked+label{opacity:1}.IllnessForm_option__CnMak{position:relative;display:-ms-flexbox;display:flex;-ms-flex-pack:center;justify-content:center}.IllnessForm_privacyNotice__kvgVs a{border-bottom:1px solid}@media screen and (max-width:768px){.IllnessForm_wrapper__LHsiR{padding-left:2.0833333333%;padding-right:2.0833333333%}}@media screen and (min-width:769px){.IllnessForm_wrapper__LHsiR{padding-top:4rem;margin-top:4rem}.IllnessForm_form__dniEO{width:41.6666666667%;font-size:21px}.IllnessForm_requiredNotice__uq6_c{width:41.6666666667%}}