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1 forms found in the DOM

Name: DoctorAnswer —

<form class="" name="DoctorAnswer" id="doctorAnswer" data-test="doctor-answer-form">
  <div class="form-group"><label class="checkbox" for="verificationType"><input class="checkbox_input -fluid" type="checkbox" name="verificationType" id="verificationType" value="true" checked="" data-uw-rm-form="nfx">
      <div class="checkbox_inner" data-test="verification-type"><span class="checkbox_box"><svg class="checkbox_checked-icon">
            <use xlink:href="#svg_checkbox-checked"></use>
          </svg><svg class="checkbox_icon">
            <use xlink:href="#svg_checkbox"></use>
          </svg></span>
        <div class="checkbox_text">I verify that Aliana Amaya or the individual named below whom they are representing, and was provided authentic documentation February 07, 2024 affirming he/she has a disability and disability-related need for 1
          support animal. If multiple support animals were prescribed then I reaffirm that each support animal has a unique nexus between the patient’s disability and his/her disability-related need that cannot be addressed by fewer support animals
          than prescribed. I attest that I am the health care provider or an authorized health care provider representative with personal knowledge about this patient and any health care professional license(s) required by law is active and in good
          standing.</div>
      </div>
    </label></div>
  <div class="form-group"><label class="checkbox" for="verificationType"><input class="checkbox_input -fluid" type="checkbox" name="verificationType" id="verificationType" value="false" data-uw-rm-form="nfx">
      <div class="checkbox_inner" data-test="verification-type"><span class="checkbox_box"><svg class="checkbox_checked-icon">
            <use xlink:href="#svg_checkbox-checked"></use>
          </svg><svg class="checkbox_icon">
            <use xlink:href="#svg_checkbox"></use>
          </svg></span>
        <div class="checkbox_text">I CANNOT affirm each of the three (3) statements above pertaining to a disability, disability-related need, and personal knowledge of this patient. (If you cannot answer "YES" to each statement, please explain why
          in the Note section below.)</div>
      </div>
    </label></div>
  <div class="form-group"><label for="name" class="form-group_label doctor-answer_label">Your name<abbr>*</abbr></label>
    <div class="form-group_controls">
      <div class="text-field" id="name-field"><input class="text-field_input" id="name" data-test="name" name="name" type="text" required="" value="Jennifer Woodward" data-uw-rm-form="nfx"></div>
      <div class="form-group_error"></div>
    </div>
  </div>
  <div class="form-group"><label for="position" class="form-group_label doctor-answer_label">Your position<abbr>*</abbr></label>
    <div class="form-group_controls">
      <div class="text-field" id="position-field"><input class="text-field_input" id="position" data-test="position" name="position" type="text" required="" value="" data-uw-rm-form="nfx"></div>
      <div class="form-group_error"></div>
    </div>
  </div>
  <div class="form-group"><label for="note" class="form-group_label doctor-answer_label">Note<abbr>*</abbr></label>
    <div class="form-group_controls">
      <div class="text-field" id="note-field"><textarea class="text-field_input doctor-answer_textarea" id="note" data-test="note" name="note" type="text" required="" data-uw-rm-form="nfx"></textarea></div>
      <div class="form-group_error"></div>
    </div>
  </div>
  <div class="doctor-answer_buttons">
    <div class="status-button"><button name="button" type="submit" data-test="submit" class="button -primary -lg">Submit</button></div>
  </div>
</form>

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SUPPORT ANIMAL VERIFICATION

I verify that Aliana Amaya or the individual named below whom they are
representing, and was provided authentic documentation February 07, 2024
affirming he/she has a disability and disability-related need for 1 support
animal. If multiple support animals were prescribed then I reaffirm that each
support animal has a unique nexus between the patient’s disability and his/her
disability-related need that cannot be addressed by fewer support animals than
prescribed. I attest that I am the health care provider or an authorized health
care provider representative with personal knowledge about this patient and any
health care professional license(s) required by law is active and in good
standing.
I CANNOT affirm each of the three (3) statements above pertaining to a
disability, disability-related need, and personal knowledge of this patient. (If
you cannot answer "YES" to each statement, please explain why in the Note
section below.)
Your name*

Your position*

Note*

Submit
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