diff --git a/pages/forms/waitlist-form.html b/pages/forms/waitlist-form.html
index a3b9fa84..90ea9098 100644
--- a/pages/forms/waitlist-form.html
+++ b/pages/forms/waitlist-form.html
@@ -56,9 +56,9 @@ <h1 class="font-heading-xl text-primary-darker">{{ page.title }}</h1>
         autocomplete="tel"
         required
       />
-      <label class="usa-label" for="state" id="state"
-        >State {% include required.html %}</label
-      >
+      <label class="usa-label" for="state">
+        State {% include required.html %}
+      </label>
       <div class="usa-combo-box">
         <select class="usa-select" id="state" name="state" required>
           {% include forms/state-options.html %}
@@ -77,32 +77,33 @@ <h1 class="font-heading-xl text-primary-darker">{{ page.title }}</h1>
         type="text"
         required
       />
-      <label class="usa-label" for="referral">How did you hear about us?</label>
-      <textarea
-        class="usa-textarea height-10"
-        id="referral"
-        name="referral"
-      ></textarea>
       <p> Currently, SimpleReport helps facilities report results for:</p>
-      <ul>
+      <ul style="padding-inline-start:20px">
         <li>COVID-19</li>
-        <li>FLU A</li>
-        <li>FLU B</li>
+        <li>Flu A</li>
+        <li>Flu B</li>
         <li>RSV</li>
       </ul>
       <label class="usa-label">Please check the boxes below for the conditions you're interested in reporting:</label>
       <br>
-          <input type="checkbox" id="COVID-19" name="COVID-19" value="COVID-19" />
-          <label for="COVID-19">COVID-19</label>
-          <br>
-          <input type="checkbox" id="FLU A" name="FLU A" value="FLU A" />
-          <label for="FLU A">FLU A</label>
-          <br>
-          <input type="checkbox" id="FLU B" name="FLU B" value="FLU B" />
-          <label for="FLU B">FLU B</label>
-          <br>
-          <input type="checkbox" id="RSV" name="RSV" value="RSV" />
-          <label for="RSV">RSV</label>
+      <div class="checkboxes">
+        <div class="usa-checkbox">
+          <input class="usa-checkbox__input" type="checkbox" id="COVID-19" name="COVID-19" value="COVID-19">
+          <label class="usa-checkbox__label" for="COVID-19">COVID-19</label>
+        </div>
+        <div class="usa-checkbox">
+          <input class="usa-checkbox__input" type="checkbox" id="Flu A" name="Flu A" value="Flu A">
+          <label class="usa-checkbox__label" for="Flu A">Flu A</label>
+        </div>
+        <div class="usa-checkbox">
+          <input class="usa-checkbox__input" type="checkbox" id="Flu B" name="Flu B" value="Flu B">
+          <label class="usa-checkbox__label" for="Flu B">Flu B</label>
+        </div>
+        <div class="usa-checkbox">
+          <input class="usa-checkbox__input" type="checkbox" id="RSV" name="RSV" value="RSV">
+          <label class="usa-checkbox__label" for="RSV">RSV</label>
+        </div>
+      </div>
       <br>
       <label class="usa-label" for="additional-conditions">If there are any additional conditions you would like to be able to report
         using SimpleReport, please enter them below.</label>
@@ -111,6 +112,12 @@ <h1 class="font-heading-xl text-primary-darker">{{ page.title }}</h1>
               id="additional-conditions"
               name="additional-conditions"
       ></textarea>
+      <label class="usa-label" for="referral">How did you hear about us?</label>
+      <textarea
+              class="usa-textarea height-10"
+              id="referral"
+              name="referral"
+      ></textarea>
       <p class="margin-bottom-0">
         By submitting this form, you agree to our
         <a href="{% link pages/tos.md %}">Terms of Service</a>.
@@ -156,6 +163,8 @@ <h3 class="usa-alert__heading">Error</h3>
         (field) => (data[field] = document.getElementById(field).value)
       );
 
+      console.log("HEY DAN LOOK HERE: " + JSON.stringify(data));
+
       try {
         let response = await fetch("/api/account-request/waitlist", {
           method: "POST",