anchor.diff:                 label: t('patient.helper.referred_by.title'),
                  autocomplete: 'off' %>
   
  -    <%= f.number_field :procedure_cost, label: t('patient.pledge_fulfillment.form.procedure_cost') %>
  -    <%= f.number_field :patient_contribution, label: t('patient.abortion_information.cost_section.patient_contribution'), autocomplete: 'off', prepend: '$' %>
  -    <%= f.number_field :naf_pledge, label: t('patient.abortion_information.cost_section.naf_pledge'), autocomplete: 'off', prepend: '$' %>
  +  <%= f.number_field :procedure_cost,
  +                     label: t('patient.pledge_fulfillment.form.procedure_cost') %>
  +  <%= f.number_field :patient_contribution,
  +                     label: t('patient.abortion_information.cost_section.patient_contribution'),
  +                     autocomplete: 'off',
  +                     prepend: '$' %>
  +  <%= f.number_field :naf_pledge,
  +                     label: t('patient.abortion_information.cost_section.naf_pledge'),
  +                     autocomplete: 'off',
  +                     prepend: '$' %>
   
  -    <%= f.check_box :pledge_sent, label: t('patient.status.key.pledge_sent') %>
  +  <%= f.check_box :pledge_sent, label: t('patient.status.key.pledge_sent') %>
   
  -  <p style="font-weight:bold"><%= t('patient.information.special_circumstances.title')%></p>
  -  <%= f.form_group :special_circumstances do %>
  -    <div class="col-sm-6">
  -      <%= f.check_box :special_circumstances, { label: t('patient.information.special_circumstances.fetal_diagnosis'), name: 'patient[special_circumstances][]', namespace: 'Fetal' }, 'Fetal diagnosis', '' %>
  -      <%= f.check_box :special_circumstances, { label: t('patient.information.special_circumstances.homelessness'), name: 'patient[special_circumstances][]', namespace: 'Home' }, 'Homelessness', '' %>
  -      <%= f.check_box :special_circumstances, { label: t('patient.information.special_circumstances.domestic_violence'), name: 'patient[special_circumstances][]', namespace: 'Domestic' }, 'Domestic violence', '' %>
  -    </div>
  -    <div class="col-sm-6">
  -    <%= f.check_box :special_circumstances, { label: t('patient.information.special_circumstances.rape'), name: 'patient[special_circumstances][]', namespace: 'Rape' }, 'Rape', '' %>
  -    <%= f.check_box :special_circumstances, { label: t('patient.information.special_circumstances.incest'), name: 'patient[special_circumstances][]', namespace: 'Incest' }, 'Incest', '' %>
  -    <%= f.check_box :special_circumstances, { label: t('patient.information.special_circumstances.prison'), name: 'patient[special_circumstances][]', namespace: 'Prison' }, 'Prison', '' %>
  -    </div>
  -  <% end %>
  +  <fieldset class="mt-5">
  +    <legend class="font-weight-bold" id="special_circumstances_label">
  +      <%= t 'patient.information.special_circumstances.title' %>    
  +    </legend>
  +
  +    <%= f.form_group :special_circumstances do %>
  +      <div class="row">
  +        <div class="col">
  +          <%= f.check_box :special_circumstances, {
  +                          label: t('patient.information.special_circumstances.fetal_diagnosis'), 
  +                          name: 'patient[special_circumstances][]',
  +                          id: 'fetal_patient_special_circumstances' },
  +                          'Fetal diagnosis', '' %>
  +          <%= f.check_box :special_circumstances, {
  +                          label: t('patient.information.special_circumstances.homelessness'),
  +                          name: 'patient[special_circumstances][]',
  +                          id: 'home_patient_special_circumstances' },
  +                          'Homelessness', '' %>
  +          <%= f.check_box :special_circumstances, {
  +                          label: t('patient.information.special_circumstances.domestic_violence'),
  +                          name: 'patient[special_circumstances][]',
  +                          id: 'domestic_patient_special_circumstances' },
  +                          'Domestic violence', '' %>
  +          <%= f.check_box :special_circumstances, {
  +                          label: t('patient.information.special_circumstances.other_medical_issue'),
  +                          name: 'patient[special_circumstances][]',
  +                          id: 'other_patient_special_circumstances' },
  +                          'Other medical issue', '' %>
  +        </div>
  +        <div class="col">
  +          <%= f.check_box :special_circumstances, {
  +                          label: t('patient.information.special_circumstances.rape'),
  +                          name: 'patient[special_circumstances][]',
  +                          id: 'rape_patient_special_circumstances' },
  +                          'Rape', '' %>
  +          <%= f.check_box :special_circumstances, {
  +                          label: t('patient.information.special_circumstances.incest'),
  +                          name: 'patient[special_circumstances][]',
  +                          id: 'incest_patient_special_circumstances' },
  +                          'Incest', '' %>
  +          <%= f.check_box :special_circumstances, {
  +                          label: t('patient.information.special_circumstances.prison'),
  +                          name: 'patient[special_circumstances][]',
  +                          id: 'prison_patient_special_circumstances' },
  +                          'Prison', '' %>
  +        </div>
  +      </div>
  +    <% end %>
  +  </fieldset>
  +
   
     <%= f.submit class: 'btn-lg btn-primary' %>
   <% end %>
  
positive.code:     <%#= notes.text_area :full_text, size: '20x5', placeholder: 'Enter notes here' %>
    <%# end %>
  
    <%= f.number_field :fund_pledge, label: t('patient.abortion_information.cost_section.fund_pledge', fund: "#{FUND}"), autocomplete: 'off' %>
  
    <%= f.number_field :age, autocomplete: 'off' %>
    <%= f.select :race_ethnicity, options_for_select(race_ethnicity_options), autocomplete: 'off' %>
    <%= f.select :clinic_id, options_for_select(clinic_options), label: t('patient.pledge_fulfillment.confirmation.clinic') %>
  
    <%= f.date_field :appointment_date, label: t('patient.shared.appt_date'), autocomplete: 'off' %>
  
    <%= f.select :insurance,
                 options_for_select(insurance_options),
                                    label: t('patient.information.insurance') %>
  
    <div class="row">
      <div class="col-sm-6">
        <%= f.select :household_size_adults,
                      options_for_select(household_size_options),
                      help: t('patient.information.household_help') %>
      </div>
      <div class="col-sm-6">
        <%= f.select :household_size_children,
                      options_for_select(household_size_options) %>
      </div>
  
negative.code: 
  <h1><%= t('patient.data_entry.patient_entry') %></h1>
  
  <%= bootstrap_form_with model: @patient,
                          url: data_entry_create_path,
                          html: { class: 'mass_entry_form' } do |f| %>
    <%= f.select :line, options_for_select(lines, current_line) %>
  
    <%= f.date_field :initial_call_date,
                     label: t('patient.new.initial_call_date') %>
  
    <%= f.text_field :name,
                     label: t('common.name'), autocomplete: 'off' %>
  
    <%= f.text_field :primary_phone,
                     label: t('common.phone'),
                     autocomplete: 'off' %>
  
    <%= f.text_field :other_contact,
                     label: t('patient.information.other_contact.name'),
                     autocomplete: 'off' %>
    <%= f.text_field :other_phone,
                     label: t('patient.information.other_contact.phone'),
                     autocomplete: 'off' %>
    <%= f.text_field :other_contact_relationship,
                     label: t('patient.information.other_contact.relationship'),
                     autocomplete: 'off'%>
  
    <div class="row">
      <div class="col">
        <%= f.select :last_menstrual_period_weeks,
                     options_for_select(weeks_options),
                     label: t('patient.dashboard.weeks_along'),
                     autocomplete: 'off' %>
      </div>
      <div class="col">
        <%= f.select :last_menstrual_period_days,
                     options_for_select(days_options, @patient.last_menstrual_period_days),
                     autocomplete: 'off',
                     label: t('common.days_along') %>
      </div>
    </div>
  
  