{"id":271449,"date":"2024-02-23T19:47:01","date_gmt":"2024-02-23T19:47:01","guid":{"rendered":"https:\/\/lavidamassagefortcollinsco.com\/?page_id=271449"},"modified":"2024-06-21T18:30:48","modified_gmt":"2024-06-21T18:30:48","slug":"skincare-intake-form","status":"publish","type":"page","link":"https:\/\/lavidamassagefortcollinsco.com\/forms\/skincare-intake-form\/","title":{"rendered":"Skincare Intake Form"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.16&#8243; background_size=&#8221;initial&#8221; background_position=&#8221;top_left&#8221; background_repeat=&#8221;repeat&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.16&#8243; custom_padding=&#8221;|||&#8221; global_colors_info=&#8221;{}&#8221; custom_padding__hover=&#8221;|||&#8221;][et_pb_text _builder_version=&#8221;4.25.1&#8243; background_size=&#8221;initial&#8221; background_position=&#8221;top_left&#8221; background_repeat=&#8221;repeat&#8221; hover_enabled=&#8221;0&#8243; global_colors_info=&#8221;{}&#8221; custom_margin=&#8221;|0px||0px|false|false&#8221; custom_padding=&#8221;|0px||0px|false|false&#8221; sticky_enabled=&#8221;0&#8243;]<\/p>\n<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context 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d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});<\/script>\n                <div class='gf_browser_unknown gform_wrapper gravity-theme gform-theme--no-framework massage-intake-form_wrapper' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_5' style='display:none'><div id='gf_5' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Skincare Intake Form<\/h2>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_5' id='gform_5' class='massage-intake-form' action='\/wp-json\/wp\/v2\/pages\/271449#gf_5' data-formid='5' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_18\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_18\" ><h3 class=\"gsection_title\">Contact<\/h3><\/div><fieldset id=\"field_5_5\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_5\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_5'>\n                            \n                            <span id='input_5_5_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.3' id='input_5_5_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_5_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_5_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.6' id='input_5_5_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_5_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_5_7\" class=\"gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_7\" ><label class='gfield_label gform-field-label' for='input_5_7'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_7' id='input_5_7' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_5_8\" class=\"gfield gfield--type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_8\" ><label class='gfield_label gform-field-label' for='input_5_8'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_5_8' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_10\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_10\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Phone Type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_10'><div class='gchoice gchoice_5_10_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.1' type='checkbox'  value='Home'  id='choice_5_10_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_10_1' id='label_5_10_1' class='gform-field-label gform-field-label--type-inline'>Home<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_10_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.2' type='checkbox'  value='Mobile'  id='choice_5_10_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_10_2' id='label_5_10_2' class='gform-field-label gform-field-label--type-inline'>Mobile<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_10_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.3' type='checkbox'  value='Work'  id='choice_5_10_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_10_3' id='label_5_10_3' class='gform-field-label gform-field-label--type-inline'>Work<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_10_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.4' type='checkbox'  value='Other'  id='choice_5_10_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_10_4' id='label_5_10_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_44\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_44\" ><legend class='gfield_label gform-field-label' >It&#039;s OK to text me!<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_44'>\n\t\t\t<div class='gchoice gchoice_5_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Yes'  id='choice_5_44_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_44_0' id='label_5_44_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='No'  id='choice_5_44_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_44_1' id='label_5_44_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_11\" class=\"gfield gfield--type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_11\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_5_11' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_11_1_container' >\n                                        <input type='text' name='input_11.1' id='input_5_11_1' value=''    aria-required='true'    \/>\n                                        <label for='input_5_11_1' id='input_5_11_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_11_3_container' >\n                                    <input type='text' name='input_11.3' id='input_5_11_3' value=''    aria-required='true'    \/>\n                                    <label for='input_5_11_3' id='input_5_11_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_11_4_container' >\n                                        <select name='input_11.4' id='input_5_11_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_5_11_4' id='input_5_11_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_11_5_container' >\n                                    <input type='text' name='input_11.5' id='input_5_11_5' value=''    aria-required='true'    \/>\n                                    <label for='input_5_11_5' id='input_5_11_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_11.6' id='input_5_11_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_5_99\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_99\" ><label class='gfield_label gform-field-label' for='input_5_99'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_99' id='input_5_99' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_15\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_15\" ><label class='gfield_label gform-field-label' for='input_5_15'>Occupation<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_5_15' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_12\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_12\" ><label class='gfield_label gform-field-label' for='input_5_12'>Emergency Contact<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_5_12' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_13\" class=\"gfield gfield--type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_13\" ><label class='gfield_label gform-field-label' for='input_5_13'>Emergency Contact Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_13' id='input_5_13' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_14\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_14\" ><label class='gfield_label gform-field-label' for='input_5_14'>Emergency Contact Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_5_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_20\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_20\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >How frequently do you receive skincare services?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_20'><div class='gchoice gchoice_5_20_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.1' type='checkbox'  value='First Time'  id='choice_5_20_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_20_1' id='label_5_20_1' class='gform-field-label gform-field-label--type-inline'>First Time<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_20_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.2' type='checkbox'  value='Once a year or less'  id='choice_5_20_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_20_2' id='label_5_20_2' class='gform-field-label gform-field-label--type-inline'>Once a year or less<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_20_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.3' type='checkbox'  value='2-3 times\/year'  id='choice_5_20_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_20_3' id='label_5_20_3' class='gform-field-label gform-field-label--type-inline'>2-3 times\/year<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_20_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.4' type='checkbox'  value='4-6 times\/yr'  id='choice_5_20_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_20_4' id='label_5_20_4' class='gform-field-label gform-field-label--type-inline'>4-6 times\/yr<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_20_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.5' type='checkbox'  value='7-10 times\/yr'  id='choice_5_20_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_20_5' id='label_5_20_5' class='gform-field-label gform-field-label--type-inline'>7-10 times\/yr<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_20_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.6' type='checkbox'  value='Monthly or more frequent'  id='choice_5_20_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_20_6' id='label_5_20_6' class='gform-field-label gform-field-label--type-inline'>Monthly or more frequent<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_17\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_17\" ><h3 class=\"gsection_title\">Medical History<\/h3><\/div><div id=\"field_5_51\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_51\" ><label class='gfield_label gform-field-label' for='input_5_51'>When was your last chemical peel?<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_5_51' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_52\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_52\" ><label class='gfield_label gform-field-label' for='input_5_52'>When was your last facial?<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_5_52' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_53\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_53\" ><label class='gfield_label gform-field-label' for='input_5_53'>Date of last facial hair removal<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_5_53' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_54\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_54\" ><legend class='gfield_label gform-field-label' >Method of Removal<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_54'>\n\t\t\t<div class='gchoice gchoice_5_54_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Chemical Removal'  id='choice_5_54_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_54_0' id='label_5_54_0' class='gform-field-label gform-field-label--type-inline'>Chemical Removal<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_54_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Laser'  id='choice_5_54_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_54_1' id='label_5_54_1' class='gform-field-label gform-field-label--type-inline'>Laser<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_54_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Shaving'  id='choice_5_54_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_54_2' id='label_5_54_2' class='gform-field-label gform-field-label--type-inline'>Shaving<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_54_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Waxing'  id='choice_5_54_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_54_3' id='label_5_54_3' class='gform-field-label gform-field-label--type-inline'>Waxing<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_54_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Threading'  id='choice_5_54_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_54_4' id='label_5_54_4' class='gform-field-label gform-field-label--type-inline'>Threading<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_54_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='gf_other_choice'  id='choice_5_54_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_54_5' id='label_5_54_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_5_54_other' class='gchoice_other_control' name='input_54_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_56\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_56\" ><legend class='gfield_label gform-field-label' >Are you currently or have you been under a physician\/dermatologist care within the last year?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_56'>\n\t\t\t<div class='gchoice gchoice_5_56_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='Yes'  id='choice_5_56_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_56_0' id='label_5_56_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_56_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='No'  id='choice_5_56_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_56_1' id='label_5_56_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_57\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_57\" ><label class='gfield_label gform-field-label' for='input_5_57'>If yes, when:<\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_5_57' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_58\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_58\" ><legend class='gfield_label gform-field-label' >Do you have recent cosmetic injectables\/dermal fillers?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_58'>\n\t\t\t<div class='gchoice gchoice_5_58_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='Yes'  id='choice_5_58_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_58_0' id='label_5_58_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_58_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='No'  id='choice_5_58_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_58_1' id='label_5_58_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_61\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_61\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >If yes, which ones?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_61'><div class='gchoice gchoice_5_61_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.1' type='checkbox'  value='FBotox\/Xeomin\/Jeuveau'  id='choice_5_61_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_61_1' id='label_5_61_1' class='gform-field-label gform-field-label--type-inline'>FBotox\/Xeomin\/Jeuveau<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_61_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.2' type='checkbox'  value='PRP\/PRF'  id='choice_5_61_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_61_2' id='label_5_61_2' class='gform-field-label gform-field-label--type-inline'>PRP\/PRF<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_61_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.3' type='checkbox'  value='Vollure\/Voluma\/Volbella'  id='choice_5_61_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_61_3' id='label_5_61_3' class='gform-field-label gform-field-label--type-inline'>Vollure\/Voluma\/Volbella<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_61_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.4' type='checkbox'  value='Radiesse\/Sculptra'  id='choice_5_61_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_61_4' id='label_5_61_4' class='gform-field-label gform-field-label--type-inline'>Radiesse\/Sculptra<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_61_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.5' type='checkbox'  value='Other'  id='choice_5_61_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_61_5' id='label_5_61_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_25\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_25\" ><label class='gfield_label gform-field-label' for='input_5_25'>Date &amp; placement of most recent injection<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_5_25' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_62\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_62\" ><legend class='gfield_label gform-field-label' >Have you been diagnosed with cancer in the last 5 years?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_62'>\n\t\t\t<div class='gchoice gchoice_5_62_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Yes'  id='choice_5_62_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_62_0' id='label_5_62_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_62_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='No'  id='choice_5_62_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_62_1' id='label_5_62_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_26\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_26\" ><label class='gfield_label gform-field-label' for='input_5_26'>List all prescription drugs, shots, or creams you are currently using<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_5_26' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_27\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_27\" ><label class='gfield_label gform-field-label' for='input_5_27'>List all medical conditions you have<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_5_27' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_64\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_64\" ><legend class='gfield_label gform-field-label' >Are you undergoing hormone replacement therapy?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_64'>\n\t\t\t<div class='gchoice gchoice_5_64_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='Yes'  id='choice_5_64_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_64_0' id='label_5_64_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_64_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='No'  id='choice_5_64_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_64_1' id='label_5_64_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_63\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_63\" ><label class='gfield_label gform-field-label' for='input_5_63'>If yes, specify<\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_5_63' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_24\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_24\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you have any allergies? Check all that apply<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_24'><div class='gchoice gchoice_5_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='None'  id='choice_5_24_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_1' id='label_5_24_1' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value='Nuts'  id='choice_5_24_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_2' id='label_5_24_2' class='gform-field-label gform-field-label--type-inline'>Nuts<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_24_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.3' type='checkbox'  value='Soy'  id='choice_5_24_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_3' id='label_5_24_3' class='gform-field-label gform-field-label--type-inline'>Soy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_24_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.4' type='checkbox'  value='Milk'  id='choice_5_24_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_4' id='label_5_24_4' class='gform-field-label gform-field-label--type-inline'>Milk<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_24_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.5' type='checkbox'  value='Latex'  id='choice_5_24_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_5' id='label_5_24_5' class='gform-field-label gform-field-label--type-inline'>Latex<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_24_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.6' type='checkbox'  value='Iodine'  id='choice_5_24_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_6' id='label_5_24_6' class='gform-field-label gform-field-label--type-inline'>Iodine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_24_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.7' type='checkbox'  value='Shellfish'  id='choice_5_24_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_7' id='label_5_24_7' class='gform-field-label gform-field-label--type-inline'>Shellfish<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_24_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.8' type='checkbox'  value='Lavendula'  id='choice_5_24_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_8' id='label_5_24_8' class='gform-field-label gform-field-label--type-inline'>Lavendula<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_24_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.9' type='checkbox'  value='Aluminum'  id='choice_5_24_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_9' id='label_5_24_9' class='gform-field-label gform-field-label--type-inline'>Aluminum<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_24_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.11' type='checkbox'  value='Fragrance'  id='choice_5_24_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_11' id='label_5_24_11' class='gform-field-label gform-field-label--type-inline'>Fragrance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_24_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.12' type='checkbox'  value='Metals'  id='choice_5_24_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_12' id='label_5_24_12' class='gform-field-label gform-field-label--type-inline'>Metals<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_24_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.13' type='checkbox'  value='Latex'  id='choice_5_24_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_13' id='label_5_24_13' class='gform-field-label gform-field-label--type-inline'>Latex<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_24_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.14' type='checkbox'  value='Pollen'  id='choice_5_24_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_14' id='label_5_24_14' class='gform-field-label gform-field-label--type-inline'>Pollen<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_24_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.15' type='checkbox'  value='Other'  id='choice_5_24_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_15' id='label_5_24_15' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_79\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_79\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you have or are you prone to?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_79'><div class='gchoice gchoice_5_79_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_79.1' type='checkbox'  value='Ingrown Hairs'  id='choice_5_79_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_79_1' id='label_5_79_1' class='gform-field-label gform-field-label--type-inline'>Ingrown Hairs<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_79_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_79.2' type='checkbox'  value='Rashes\/Eczema'  id='choice_5_79_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_79_2' id='label_5_79_2' class='gform-field-label gform-field-label--type-inline'>Rashes\/Eczema<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_79_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_79.3' type='checkbox'  value='Scarring'  id='choice_5_79_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_79_3' id='label_5_79_3' class='gform-field-label gform-field-label--type-inline'>Scarring<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_79_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_79.4' type='checkbox'  value='Athlete\u2019s Foot'  id='choice_5_79_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_79_4' id='label_5_79_4' class='gform-field-label gform-field-label--type-inline'>Athlete\u2019s Foot<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_79_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_79.5' type='checkbox'  value='Burns\/Sunburns'  id='choice_5_79_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_79_5' id='label_5_79_5' class='gform-field-label gform-field-label--type-inline'>Burns\/Sunburns<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_79_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_79.6' type='checkbox'  value='Bruising'  id='choice_5_79_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_79_6' id='label_5_79_6' class='gform-field-label gform-field-label--type-inline'>Bruising<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_79_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_79.7' type='checkbox'  value='Hyper-pigmentation'  id='choice_5_79_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_79_7' id='label_5_79_7' class='gform-field-label gform-field-label--type-inline'>Hyper-pigmentation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_79_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_79.8' type='checkbox'  value='Open Wounds\/Sores'  id='choice_5_79_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_79_8' id='label_5_79_8' class='gform-field-label gform-field-label--type-inline'>Open Wounds\/Sores<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_78\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_78\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Have you used any of the following?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_78'><div class='gchoice gchoice_5_78_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.1' type='checkbox'  value='Accutane'  id='choice_5_78_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_78_1' id='label_5_78_1' class='gform-field-label gform-field-label--type-inline'>Accutane<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_78_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.2' type='checkbox'  value='Retin-A'  id='choice_5_78_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_78_2' id='label_5_78_2' class='gform-field-label gform-field-label--type-inline'>Retin-A<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_78_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.3' type='checkbox'  value='Alpha-Hydroxy Acid'  id='choice_5_78_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_78_3' id='label_5_78_3' class='gform-field-label gform-field-label--type-inline'>Alpha-Hydroxy Acid<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_78_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.4' type='checkbox'  value='Glycolic Acid'  id='choice_5_78_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_78_4' id='label_5_78_4' class='gform-field-label gform-field-label--type-inline'>Glycolic Acid<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_78_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.5' type='checkbox'  value='Resorcino'  id='choice_5_78_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_78_5' id='label_5_78_5' class='gform-field-label gform-field-label--type-inline'>Resorcino<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_78_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.6' type='checkbox'  value='Scrub \/Peel'  id='choice_5_78_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_78_6' id='label_5_78_6' class='gform-field-label gform-field-label--type-inline'>Scrub \/Peel<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_81\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_81\" ><legend class='gfield_label gform-field-label' >Do you use a Tanning Bed?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_81'>\n\t\t\t<div class='gchoice gchoice_5_81_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='Yes'  id='choice_5_81_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_81_0' id='label_5_81_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_81_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='No'  id='choice_5_81_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_81_1' id='label_5_81_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_82\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_82\" ><label class='gfield_label gform-field-label' for='input_5_82'>If yes, when and how often?<\/label><div class='ginput_container ginput_container_text'><input name='input_82' id='input_5_82' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_80\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_80\" ><legend class='gfield_label gform-field-label' >Have you had recent natural sun exposure?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_80'>\n\t\t\t<div class='gchoice gchoice_5_80_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Yes'  id='choice_5_80_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_80_0' id='label_5_80_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_80_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='No'  id='choice_5_80_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_80_1' id='label_5_80_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_83\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_83\" ><label class='gfield_label gform-field-label' for='input_5_83'>If yes, when and how often?<\/label><div class='ginput_container ginput_container_text'><input name='input_83' id='input_5_83' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_84\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_84\" ><legend class='gfield_label gform-field-label' >Have you used any other skin thinning medications?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_84'>\n\t\t\t<div class='gchoice gchoice_5_84_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='Yes'  id='choice_5_84_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_84_0' id='label_5_84_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_84_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='No'  id='choice_5_84_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_84_1' id='label_5_84_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_85\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_85\" ><label class='gfield_label gform-field-label' for='input_5_85'>If yes, which ones?<\/label><div class='ginput_container ginput_container_text'><input name='input_85' id='input_5_85' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_86\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_86\" ><legend class='gfield_label gform-field-label' >Do you use Retinol\/vitamin A derivative products?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_86'>\n\t\t\t<div class='gchoice gchoice_5_86_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='Yes'  id='choice_5_86_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_86_0' id='label_5_86_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_86_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='No'  id='choice_5_86_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_86_1' id='label_5_86_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_87\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_87\" ><label class='gfield_label gform-field-label' for='input_5_87'>If yes, Specify which kind &amp; date of last use<\/label><div class='ginput_container ginput_container_text'><input name='input_87' id='input_5_87' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_88\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_88\" ><h3 class=\"gsection_title\">SKINCARE PRODUCTS YOU CURRENTLY USE DAILY\/WEEKLY<\/h3><\/div><div id=\"field_5_89\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_89\" ><label class='gfield_label gform-field-label' for='input_5_89'>Cleanser(s)<\/label><div class='ginput_container ginput_container_text'><input name='input_89' id='input_5_89' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_90\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_90\" ><label class='gfield_label gform-field-label' for='input_5_90'>Serums<\/label><div class='ginput_container ginput_container_text'><input name='input_90' id='input_5_90' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_91\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_91\" ><label class='gfield_label gform-field-label' for='input_5_91'>Toner<\/label><div class='ginput_container ginput_container_text'><input name='input_91' id='input_5_91' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_92\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_92\" ><label class='gfield_label gform-field-label' for='input_5_92'>Eye Serum\/Cream<\/label><div class='ginput_container ginput_container_text'><input name='input_92' id='input_5_92' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_93\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_93\" ><label class='gfield_label gform-field-label' for='input_5_93'>Exfoliant<\/label><div class='ginput_container ginput_container_text'><input name='input_93' id='input_5_93' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_94\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_94\" ><label class='gfield_label gform-field-label' for='input_5_94'>Moisturizer<\/label><div class='ginput_container ginput_container_text'><input name='input_94' id='input_5_94' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_95\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_95\" ><label class='gfield_label gform-field-label' for='input_5_95'>SPF<\/label><div class='ginput_container ginput_container_text'><input name='input_95' id='input_5_95' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_96\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_96\" ><label class='gfield_label gform-field-label' for='input_5_96'>Other<\/label><div class='ginput_container ginput_container_text'><input name='input_96' id='input_5_96' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_97\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_97\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What type of skin do you have?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_97'><div class='gchoice gchoice_5_97_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_97.1' type='checkbox'  value='Normal'  id='choice_5_97_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_97_1' id='label_5_97_1' class='gform-field-label gform-field-label--type-inline'>Normal<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_97_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_97.2' type='checkbox'  value='Dry'  id='choice_5_97_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_97_2' id='label_5_97_2' class='gform-field-label gform-field-label--type-inline'>Dry<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_97_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_97.3' type='checkbox'  value='Oily'  id='choice_5_97_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_97_3' id='label_5_97_3' class='gform-field-label gform-field-label--type-inline'>Oily<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_97_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_97.4' type='checkbox'  value='Combo Dry'  id='choice_5_97_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_97_4' id='label_5_97_4' class='gform-field-label gform-field-label--type-inline'>Combo Dry<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_97_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_97.5' type='checkbox'  value='Combo Oily'  id='choice_5_97_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_97_5' id='label_5_97_5' class='gform-field-label gform-field-label--type-inline'>Combo Oily<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_97_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_97.6' type='checkbox'  value='Acne Prone'  id='choice_5_97_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_97_6' id='label_5_97_6' class='gform-field-label gform-field-label--type-inline'>Acne Prone<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_97_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_97.7' type='checkbox'  value='Sensitive'  id='choice_5_97_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_97_7' id='label_5_97_7' class='gform-field-label gform-field-label--type-inline'>Sensitive<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_98\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_98\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What are your concerns today?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_98'><div class='gchoice gchoice_5_98_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.1' type='checkbox'  value='Uneven Skin Ton'  id='choice_5_98_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_98_1' id='label_5_98_1' class='gform-field-label gform-field-label--type-inline'>Uneven Skin Ton<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_98_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.2' type='checkbox'  value='Hyperpigmentation'  id='choice_5_98_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_98_2' id='label_5_98_2' class='gform-field-label gform-field-label--type-inline'>Hyperpigmentation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_98_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.3' type='checkbox'  value='Melasma'  id='choice_5_98_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_98_3' id='label_5_98_3' class='gform-field-label gform-field-label--type-inline'>Melasma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_98_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.4' type='checkbox'  value='Blackheads'  id='choice_5_98_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_98_4' id='label_5_98_4' class='gform-field-label gform-field-label--type-inline'>Blackheads<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_98_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.5' type='checkbox'  value='Acne'  id='choice_5_98_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_98_5' id='label_5_98_5' class='gform-field-label gform-field-label--type-inline'>Acne<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_98_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.6' type='checkbox'  value='Fine Lines'  id='choice_5_98_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_98_6' id='label_5_98_6' class='gform-field-label gform-field-label--type-inline'>Fine Lines<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_98_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.7' type='checkbox'  value='Wrinkles'  id='choice_5_98_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_98_7' id='label_5_98_7' class='gform-field-label gform-field-label--type-inline'>Wrinkles<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_98_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.8' type='checkbox'  value='Dull\/Dry Skin'  id='choice_5_98_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_98_8' id='label_5_98_8' class='gform-field-label gform-field-label--type-inline'>Dull\/Dry Skin<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_98_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.9' type='checkbox'  value='Rosacea'  id='choice_5_98_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_98_9' id='label_5_98_9' class='gform-field-label gform-field-label--type-inline'>Rosacea<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_98_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.11' type='checkbox'  value='Excessive Oil'  id='choice_5_98_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_98_11' id='label_5_98_11' class='gform-field-label gform-field-label--type-inline'>Excessive Oil<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_98_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.12' type='checkbox'  value='Dry Lips'  id='choice_5_98_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_98_12' id='label_5_98_12' class='gform-field-label gform-field-label--type-inline'>Dry Lips<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_98_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.13' type='checkbox'  value='Dark Circles'  id='choice_5_98_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_98_13' id='label_5_98_13' class='gform-field-label gform-field-label--type-inline'>Dark Circles<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_98_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.14' type='checkbox'  value='Relaxation'  id='choice_5_98_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_98_14' id='label_5_98_14' class='gform-field-label gform-field-label--type-inline'>Relaxation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_98_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.15' type='checkbox'  value='Stress Relief'  id='choice_5_98_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_98_15' id='label_5_98_15' class='gform-field-label gform-field-label--type-inline'>Stress Relief<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_65\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_65\" ><h3 class=\"gsection_title\">FEMALE GUESTS<\/h3><\/div><fieldset id=\"field_5_66\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_66\" ><legend class='gfield_label gform-field-label' >Are you pregnant or trying to get pregnant?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_66'>\n\t\t\t<div class='gchoice gchoice_5_66_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='Yes'  id='choice_5_66_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_66_0' id='label_5_66_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_66_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='No'  id='choice_5_66_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_66_1' id='label_5_66_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_30\" ><legend class='gfield_label gform-field-label' >Are you lactating?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_30'>\n\t\t\t<div class='gchoice gchoice_5_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Yes'  id='choice_5_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_30_0' id='label_5_30_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='No'  id='choice_5_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_30_1' id='label_5_30_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_67\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_67\" ><legend class='gfield_label gform-field-label' >Any recent changes to your contraceptive treatment?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_67'>\n\t\t\t<div class='gchoice gchoice_5_67_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='Yes'  id='choice_5_67_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_67_0' id='label_5_67_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_67_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='No'  id='choice_5_67_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_67_1' id='label_5_67_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_69\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_69\" ><label class='gfield_label gform-field-label' for='input_5_69'>If yes, list name of contraceptive<\/label><div class='ginput_container ginput_container_text'><input name='input_69' id='input_5_69' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_72\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_72\" ><legend class='gfield_label gform-field-label' >Are you taking oral contraceptives?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_72'>\n\t\t\t<div class='gchoice gchoice_5_72_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='Yes'  id='choice_5_72_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_72_0' id='label_5_72_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_72_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='No'  id='choice_5_72_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_72_1' id='label_5_72_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_49\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_49\" ><label class='gfield_label gform-field-label' for='input_5_49'>If yes, specify:<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_5_49' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_73\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_73\" ><legend class='gfield_label gform-field-label' >Are you going through menopause?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_73'>\n\t\t\t<div class='gchoice gchoice_5_73_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_73' type='radio' value='Yes'  id='choice_5_73_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_73_0' id='label_5_73_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_73_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_73' type='radio' value='No'  id='choice_5_73_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_73_1' id='label_5_73_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_74\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_74\" ><label class='gfield_label gform-field-label' for='input_5_74'>If yes, list any issues you are having since this hormonal change:<\/label><div class='ginput_container ginput_container_text'><input name='input_74' id='input_5_74' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_75\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_75\" ><h3 class=\"gsection_title\">MALE GUESTS<\/h3><\/div><fieldset id=\"field_5_33\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_33\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What is your current shaving system<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_33'><div class='gchoice gchoice_5_33_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.1' type='checkbox'  value='Wet shave'  id='choice_5_33_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_33_1' id='label_5_33_1' class='gform-field-label gform-field-label--type-inline'>Wet shave<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_33_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.2' type='checkbox'  value='Electric'  id='choice_5_33_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_33_2' id='label_5_33_2' class='gform-field-label gform-field-label--type-inline'>Electric<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_33_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.3' type='checkbox'  value='Disposable razor'  id='choice_5_33_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_33_3' id='label_5_33_3' class='gform-field-label gform-field-label--type-inline'>Disposable razor<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_33_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.4' type='checkbox'  value='Laser Hair Removal'  id='choice_5_33_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_33_4' id='label_5_33_4' class='gform-field-label gform-field-label--type-inline'>Laser Hair Removal<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_34\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_34\" ><legend class='gfield_label gform-field-label' >Do you experience irritation from shaving?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_34'>\n\t\t\t<div class='gchoice gchoice_5_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Yes'  id='choice_5_34_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_34_0' id='label_5_34_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='No'  id='choice_5_34_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_34_1' id='label_5_34_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_76\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_76\" ><legend class='gfield_label gform-field-label' >Do you get ingrown hairs after shaving?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_76'>\n\t\t\t<div class='gchoice gchoice_5_76_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Yes'  id='choice_5_76_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_76_0' id='label_5_76_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_76_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='No'  id='choice_5_76_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_76_1' id='label_5_76_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_41\" class=\"gfield gfield--type-consent gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_41\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_41.1' id='input_5_41_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_5_41\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_5_41_1' >I agree to the notice.<\/label><input type='hidden' name='input_41.2' value='I agree to the notice.' class='gform_hidden' \/><input type='hidden' name='input_41.3' value='2' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_5_41'>My signature below constitutes acknowledgement that I have read and understand the foregoing consent form and agree to the treatment. I consent to photographs being taken to evaluate treatment efficacy and for social media use. No photographs revealing my identity will be used without my written consent. I hold harmless LaVida Massage + Skincare, the Esthetician, and affiliates of all circumstances that may occur during my treatment. I agree that I am willing to follow recommendations by my Esthetician for home care. I will be responsible for following home regimens that can minimize or eliminate possible negative reactions, including recognizing the importance of adhering to sunscreen. If I may have additional questions or concerns regarding my treatment or suggested home product\/post-treatment care, I will consult my Esthetician immediately. I HEREBY AFFIRM:  I AM 18 YEARS OF AGE OR OLDER.  I HAVE CAREFULLY READ THIS DOCUMENT, AND I UNDERSTAND ITS CONTENTS.  I AM AWARE THIS DOCUMENT IS A RELEASE OF ALL LIABILITY AND A CONTRACT ENFORCEABLE AGAINST ME (AND MY HEIRS, NEXT OF KIN, DISTRIBUTEES, GUARDIANS, LEGAL REPRESENTATIVES, EXECUTORS, ADMINISTRATORS, SUCCESSORS AND ASSIGNS) IN A COURT OF LAW.  I HAVE SIGNED THIS DOCUMENT OF MY OWN FREE WILL.<\/div><\/fieldset><div id=\"field_5_42\" class=\"gfield gfield--type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_42\" ><label class='gfield_label gform-field-label' for='input_5_42'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_5_42_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_5_42_valid' id='input_5_42_valid' \/><canvas id='input_5_42' width='300' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_5_100\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_100\" ><label class='gfield_label gform-field-label' for='input_5_100'>Phone<\/label><div class='ginput_container'><input name='input_100' id='input_5_100' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_5_100'>This field is for validation purposes and should be left unchanged.<\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_5' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' value='submit'  \/> <input type='hidden' name='gform_ajax' value='form_id=5&amp;title=1&amp;description=&amp;tabindex=0&amp;theme=gravity-theme&amp;hash=7d078ba33f732f8d9c03611f8a5e0953' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_5' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_5' id='gform_theme_5' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_5' id='gform_style_settings_5' value='' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_5' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='5' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_5' value='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*\/\n<\/script>\n\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"\n                <div class='gf_browser_unknown gform_wrapper gravity-theme gform-theme--no-framework massage-intake-form_wrapper' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_5' style='display:none'><div id='gf_5' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Skincare Intake Form<\/h2>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_5' id='gform_5' class='massage-intake-form' action='\/wp-json\/wp\/v2\/pages\/271449#gf_5' data-formid='5' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_18\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_18\" ><h3 class=\"gsection_title\">Contact<\/h3><\/div><fieldset id=\"field_5_5\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_5\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_5'>\n                            \n                            <span id='input_5_5_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.3' id='input_5_5_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_5_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_5_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.6' id='input_5_5_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_5_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_5_7\" class=\"gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_7\" ><label class='gfield_label gform-field-label' for='input_5_7'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_7' id='input_5_7' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_5_8\" class=\"gfield gfield--type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_8\" ><label class='gfield_label gform-field-label' for='input_5_8'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_5_8' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_10\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_10\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Phone Type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_10'><div class='gchoice gchoice_5_10_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.1' type='checkbox'  value='Home'  id='choice_5_10_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_10_1' id='label_5_10_1' class='gform-field-label gform-field-label--type-inline'>Home<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_10_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.2' type='checkbox'  value='Mobile'  id='choice_5_10_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_10_2' id='label_5_10_2' class='gform-field-label gform-field-label--type-inline'>Mobile<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_10_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.3' type='checkbox'  value='Work'  id='choice_5_10_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_10_3' id='label_5_10_3' class='gform-field-label gform-field-label--type-inline'>Work<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_10_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.4' type='checkbox'  value='Other'  id='choice_5_10_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_10_4' id='label_5_10_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_44\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_44\" ><legend class='gfield_label gform-field-label' >It&#039;s OK to text me!<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_44'>\n\t\t\t<div class='gchoice gchoice_5_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Yes'  id='choice_5_44_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_44_0' id='label_5_44_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='No'  id='choice_5_44_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_44_1' id='label_5_44_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_11\" class=\"gfield gfield--type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_11\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_5_11' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_11_1_container' >\n                                        <input type='text' name='input_11.1' id='input_5_11_1' value=''    aria-required='true'    \/>\n                                        <label for='input_5_11_1' id='input_5_11_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_11_3_container' >\n                                    <input type='text' name='input_11.3' id='input_5_11_3' value=''    aria-required='true'    \/>\n                                    <label for='input_5_11_3' id='input_5_11_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_11_4_container' >\n                                        <select name='input_11.4' id='input_5_11_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_5_11_4' id='input_5_11_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_11_5_container' >\n                                    <input type='text' name='input_11.5' id='input_5_11_5' value=''    aria-required='true'    \/>\n                                    <label for='input_5_11_5' id='input_5_11_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_11.6' id='input_5_11_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_5_99\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_99\" ><label class='gfield_label gform-field-label' for='input_5_99'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_99' id='input_5_99' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_15\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_15\" ><label class='gfield_label gform-field-label' for='input_5_15'>Occupation<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_5_15' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_12\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_12\" ><label class='gfield_label gform-field-label' for='input_5_12'>Emergency Contact<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_5_12' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_13\" class=\"gfield gfield--type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_13\" ><label class='gfield_label gform-field-label' for='input_5_13'>Emergency Contact Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_13' id='input_5_13' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_14\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_14\" ><label class='gfield_label gform-field-label' for='input_5_14'>Emergency Contact Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_5_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_20\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_20\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >How frequently do you receive skincare services?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_20'><div class='gchoice gchoice_5_20_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.1' type='checkbox'  value='First Time'  id='choice_5_20_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_20_1' id='label_5_20_1' class='gform-field-label gform-field-label--type-inline'>First Time<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_20_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.2' type='checkbox'  value='Once a year or less'  id='choice_5_20_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_20_2' id='label_5_20_2' class='gform-field-label gform-field-label--type-inline'>Once a year or less<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_20_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.3' type='checkbox'  value='2-3 times\/year'  id='choice_5_20_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_20_3' id='label_5_20_3' class='gform-field-label gform-field-label--type-inline'>2-3 times\/year<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_20_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.4' type='checkbox'  value='4-6 times\/yr'  id='choice_5_20_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_20_4' id='label_5_20_4' class='gform-field-label gform-field-label--type-inline'>4-6 times\/yr<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_20_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.5' type='checkbox'  value='7-10 times\/yr'  id='choice_5_20_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_20_5' id='label_5_20_5' class='gform-field-label gform-field-label--type-inline'>7-10 times\/yr<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_20_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.6' type='checkbox'  value='Monthly or more frequent'  id='choice_5_20_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_20_6' id='label_5_20_6' class='gform-field-label gform-field-label--type-inline'>Monthly or more frequent<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_17\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_17\" ><h3 class=\"gsection_title\">Medical History<\/h3><\/div><div id=\"field_5_51\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_51\" ><label class='gfield_label gform-field-label' for='input_5_51'>When was your last chemical peel?<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_5_51' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_52\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_52\" ><label class='gfield_label gform-field-label' for='input_5_52'>When was your last facial?<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_5_52' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_53\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_53\" ><label class='gfield_label gform-field-label' for='input_5_53'>Date of last facial hair removal<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_5_53' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_54\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_54\" ><legend class='gfield_label gform-field-label' >Method of Removal<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_54'>\n\t\t\t<div class='gchoice gchoice_5_54_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Chemical Removal'  id='choice_5_54_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_54_0' id='label_5_54_0' class='gform-field-label gform-field-label--type-inline'>Chemical Removal<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_54_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Laser'  id='choice_5_54_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_54_1' id='label_5_54_1' class='gform-field-label gform-field-label--type-inline'>Laser<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_54_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Shaving'  id='choice_5_54_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_54_2' id='label_5_54_2' class='gform-field-label gform-field-label--type-inline'>Shaving<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_54_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Waxing'  id='choice_5_54_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_54_3' id='label_5_54_3' class='gform-field-label gform-field-label--type-inline'>Waxing<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_54_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Threading'  id='choice_5_54_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_54_4' id='label_5_54_4' class='gform-field-label gform-field-label--type-inline'>Threading<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_54_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='gf_other_choice'  id='choice_5_54_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_54_5' id='label_5_54_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_5_54_other' class='gchoice_other_control' name='input_54_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_56\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_56\" ><legend class='gfield_label gform-field-label' >Are you currently or have you been under a physician\/dermatologist care within the last year?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_56'>\n\t\t\t<div class='gchoice gchoice_5_56_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='Yes'  id='choice_5_56_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_56_0' id='label_5_56_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_56_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='No'  id='choice_5_56_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_56_1' id='label_5_56_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_57\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_57\" ><label class='gfield_label gform-field-label' for='input_5_57'>If yes, when:<\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_5_57' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_58\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_58\" ><legend class='gfield_label gform-field-label' >Do you have recent cosmetic injectables\/dermal fillers?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_58'>\n\t\t\t<div class='gchoice gchoice_5_58_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='Yes'  id='choice_5_58_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_58_0' id='label_5_58_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_58_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='No'  id='choice_5_58_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_58_1' id='label_5_58_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_61\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_61\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >If yes, which ones?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_61'><div class='gchoice gchoice_5_61_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.1' type='checkbox'  value='FBotox\/Xeomin\/Jeuveau'  id='choice_5_61_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_61_1' id='label_5_61_1' class='gform-field-label gform-field-label--type-inline'>FBotox\/Xeomin\/Jeuveau<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_61_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.2' type='checkbox'  value='PRP\/PRF'  id='choice_5_61_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_61_2' id='label_5_61_2' class='gform-field-label gform-field-label--type-inline'>PRP\/PRF<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_61_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.3' type='checkbox'  value='Vollure\/Voluma\/Volbella'  id='choice_5_61_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_61_3' id='label_5_61_3' class='gform-field-label gform-field-label--type-inline'>Vollure\/Voluma\/Volbella<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_61_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.4' type='checkbox'  value='Radiesse\/Sculptra'  id='choice_5_61_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_61_4' id='label_5_61_4' class='gform-field-label gform-field-label--type-inline'>Radiesse\/Sculptra<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_61_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.5' type='checkbox'  value='Other'  id='choice_5_61_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_61_5' id='label_5_61_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_25\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_25\" ><label class='gfield_label gform-field-label' for='input_5_25'>Date &amp; placement of most recent injection<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_5_25' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_62\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_62\" ><legend class='gfield_label gform-field-label' >Have you been diagnosed with cancer in the last 5 years?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_62'>\n\t\t\t<div class='gchoice gchoice_5_62_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Yes'  id='choice_5_62_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_62_0' id='label_5_62_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_62_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='No'  id='choice_5_62_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_62_1' id='label_5_62_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_26\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_26\" ><label class='gfield_label gform-field-label' for='input_5_26'>List all prescription drugs, shots, or creams you are currently using<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_5_26' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_27\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_27\" ><label class='gfield_label gform-field-label' for='input_5_27'>List all medical conditions you have<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_5_27' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_64\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_64\" ><legend class='gfield_label gform-field-label' >Are you undergoing hormone replacement therapy?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_64'>\n\t\t\t<div class='gchoice gchoice_5_64_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='Yes'  id='choice_5_64_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_64_0' id='label_5_64_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_64_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='No'  id='choice_5_64_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_64_1' id='label_5_64_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_63\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_63\" ><label class='gfield_label gform-field-label' for='input_5_63'>If yes, specify<\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_5_63' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_24\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_24\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you have any allergies? Check all that apply<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_24'><div class='gchoice gchoice_5_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='None'  id='choice_5_24_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_1' id='label_5_24_1' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value='Nuts'  id='choice_5_24_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_2' id='label_5_24_2' class='gform-field-label gform-field-label--type-inline'>Nuts<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_24_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.3' type='checkbox'  value='Soy'  id='choice_5_24_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_3' id='label_5_24_3' class='gform-field-label gform-field-label--type-inline'>Soy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_24_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.4' type='checkbox'  value='Milk'  id='choice_5_24_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_4' id='label_5_24_4' class='gform-field-label gform-field-label--type-inline'>Milk<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_24_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.5' type='checkbox'  value='Latex'  id='choice_5_24_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_5' id='label_5_24_5' class='gform-field-label gform-field-label--type-inline'>Latex<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_24_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.6' type='checkbox'  value='Iodine'  id='choice_5_24_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_6' id='label_5_24_6' class='gform-field-label gform-field-label--type-inline'>Iodine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_24_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.7' type='checkbox'  value='Shellfish'  id='choice_5_24_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_7' id='label_5_24_7' class='gform-field-label gform-field-label--type-inline'>Shellfish<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_24_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.8' type='checkbox'  value='Lavendula'  id='choice_5_24_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_8' id='label_5_24_8' class='gform-field-label gform-field-label--type-inline'>Lavendula<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_24_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.9' type='checkbox'  value='Aluminum'  id='choice_5_24_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_9' id='label_5_24_9' class='gform-field-label gform-field-label--type-inline'>Aluminum<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_24_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.11' type='checkbox'  value='Fragrance'  id='choice_5_24_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_11' id='label_5_24_11' class='gform-field-label gform-field-label--type-inline'>Fragrance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_24_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.12' type='checkbox'  value='Metals'  id='choice_5_24_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_12' id='label_5_24_12' class='gform-field-label gform-field-label--type-inline'>Metals<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_24_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.13' type='checkbox'  value='Latex'  id='choice_5_24_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_13' id='label_5_24_13' class='gform-field-label gform-field-label--type-inline'>Latex<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_24_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.14' type='checkbox'  value='Pollen'  id='choice_5_24_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_14' id='label_5_24_14' class='gform-field-label gform-field-label--type-inline'>Pollen<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_24_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.15' type='checkbox'  value='Other'  id='choice_5_24_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_15' id='label_5_24_15' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_79\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_79\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you have or are you prone to?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_79'><div class='gchoice gchoice_5_79_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_79.1' type='checkbox'  value='Ingrown Hairs'  id='choice_5_79_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_79_1' id='label_5_79_1' class='gform-field-label gform-field-label--type-inline'>Ingrown Hairs<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_79_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_79.2' type='checkbox'  value='Rashes\/Eczema'  id='choice_5_79_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_79_2' id='label_5_79_2' class='gform-field-label gform-field-label--type-inline'>Rashes\/Eczema<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_79_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_79.3' type='checkbox'  value='Scarring'  id='choice_5_79_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_79_3' id='label_5_79_3' class='gform-field-label gform-field-label--type-inline'>Scarring<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_79_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_79.4' type='checkbox'  value='Athlete\u2019s Foot'  id='choice_5_79_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_79_4' id='label_5_79_4' class='gform-field-label gform-field-label--type-inline'>Athlete\u2019s Foot<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_79_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_79.5' type='checkbox'  value='Burns\/Sunburns'  id='choice_5_79_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_79_5' id='label_5_79_5' class='gform-field-label gform-field-label--type-inline'>Burns\/Sunburns<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_79_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_79.6' type='checkbox'  value='Bruising'  id='choice_5_79_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_79_6' id='label_5_79_6' class='gform-field-label gform-field-label--type-inline'>Bruising<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_79_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_79.7' type='checkbox'  value='Hyper-pigmentation'  id='choice_5_79_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_79_7' id='label_5_79_7' class='gform-field-label gform-field-label--type-inline'>Hyper-pigmentation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_79_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_79.8' type='checkbox'  value='Open Wounds\/Sores'  id='choice_5_79_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_79_8' id='label_5_79_8' class='gform-field-label gform-field-label--type-inline'>Open Wounds\/Sores<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_78\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_78\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Have you used any of the following?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_78'><div class='gchoice gchoice_5_78_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.1' type='checkbox'  value='Accutane'  id='choice_5_78_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_78_1' id='label_5_78_1' class='gform-field-label gform-field-label--type-inline'>Accutane<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_78_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.2' type='checkbox'  value='Retin-A'  id='choice_5_78_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_78_2' id='label_5_78_2' class='gform-field-label gform-field-label--type-inline'>Retin-A<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_78_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.3' type='checkbox'  value='Alpha-Hydroxy Acid'  id='choice_5_78_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_78_3' id='label_5_78_3' class='gform-field-label gform-field-label--type-inline'>Alpha-Hydroxy Acid<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_78_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.4' type='checkbox'  value='Glycolic Acid'  id='choice_5_78_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_78_4' id='label_5_78_4' class='gform-field-label gform-field-label--type-inline'>Glycolic Acid<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_78_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.5' type='checkbox'  value='Resorcino'  id='choice_5_78_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_78_5' id='label_5_78_5' class='gform-field-label gform-field-label--type-inline'>Resorcino<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_78_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.6' type='checkbox'  value='Scrub \/Peel'  id='choice_5_78_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_78_6' id='label_5_78_6' class='gform-field-label gform-field-label--type-inline'>Scrub \/Peel<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_81\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_81\" ><legend class='gfield_label gform-field-label' >Do you use a Tanning Bed?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_81'>\n\t\t\t<div class='gchoice gchoice_5_81_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='Yes'  id='choice_5_81_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_81_0' id='label_5_81_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_81_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='No'  id='choice_5_81_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_81_1' id='label_5_81_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_82\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_82\" ><label class='gfield_label gform-field-label' for='input_5_82'>If yes, when and how often?<\/label><div class='ginput_container ginput_container_text'><input name='input_82' id='input_5_82' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_80\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_80\" ><legend class='gfield_label gform-field-label' >Have you had recent natural sun exposure?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_80'>\n\t\t\t<div class='gchoice gchoice_5_80_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Yes'  id='choice_5_80_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_80_0' id='label_5_80_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_80_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='No'  id='choice_5_80_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_80_1' id='label_5_80_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_83\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_83\" ><label class='gfield_label gform-field-label' for='input_5_83'>If yes, when and how often?<\/label><div class='ginput_container ginput_container_text'><input name='input_83' id='input_5_83' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_84\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_84\" ><legend class='gfield_label gform-field-label' >Have you used any other skin thinning medications?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_84'>\n\t\t\t<div class='gchoice gchoice_5_84_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='Yes'  id='choice_5_84_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_84_0' id='label_5_84_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_84_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='No'  id='choice_5_84_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_84_1' id='label_5_84_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_85\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_85\" ><label class='gfield_label gform-field-label' for='input_5_85'>If yes, which ones?<\/label><div class='ginput_container ginput_container_text'><input name='input_85' id='input_5_85' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_86\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_86\" ><legend class='gfield_label gform-field-label' >Do you use Retinol\/vitamin A derivative products?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_86'>\n\t\t\t<div class='gchoice gchoice_5_86_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='Yes'  id='choice_5_86_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_86_0' id='label_5_86_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_86_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='No'  id='choice_5_86_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_86_1' id='label_5_86_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_87\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_87\" ><label class='gfield_label gform-field-label' for='input_5_87'>If yes, Specify which kind &amp; date of last use<\/label><div class='ginput_container ginput_container_text'><input name='input_87' id='input_5_87' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_88\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_88\" ><h3 class=\"gsection_title\">SKINCARE PRODUCTS YOU CURRENTLY USE DAILY\/WEEKLY<\/h3><\/div><div id=\"field_5_89\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_89\" ><label class='gfield_label gform-field-label' for='input_5_89'>Cleanser(s)<\/label><div class='ginput_container ginput_container_text'><input name='input_89' id='input_5_89' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_90\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_90\" ><label class='gfield_label gform-field-label' for='input_5_90'>Serums<\/label><div class='ginput_container ginput_container_text'><input name='input_90' id='input_5_90' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_91\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_91\" ><label class='gfield_label gform-field-label' for='input_5_91'>Toner<\/label><div class='ginput_container ginput_container_text'><input name='input_91' id='input_5_91' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_92\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_92\" ><label class='gfield_label gform-field-label' for='input_5_92'>Eye Serum\/Cream<\/label><div class='ginput_container ginput_container_text'><input name='input_92' id='input_5_92' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_93\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_93\" ><label class='gfield_label gform-field-label' for='input_5_93'>Exfoliant<\/label><div class='ginput_container ginput_container_text'><input name='input_93' id='input_5_93' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_94\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_94\" ><label class='gfield_label gform-field-label' for='input_5_94'>Moisturizer<\/label><div class='ginput_container ginput_container_text'><input name='input_94' id='input_5_94' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_95\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_95\" ><label class='gfield_label gform-field-label' for='input_5_95'>SPF<\/label><div class='ginput_container ginput_container_text'><input name='input_95' id='input_5_95' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_96\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_96\" ><label class='gfield_label gform-field-label' for='input_5_96'>Other<\/label><div class='ginput_container ginput_container_text'><input name='input_96' id='input_5_96' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_97\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_97\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What type of skin do you have?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_97'><div class='gchoice gchoice_5_97_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_97.1' type='checkbox'  value='Normal'  id='choice_5_97_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_97_1' id='label_5_97_1' class='gform-field-label gform-field-label--type-inline'>Normal<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_97_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_97.2' type='checkbox'  value='Dry'  id='choice_5_97_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_97_2' id='label_5_97_2' class='gform-field-label gform-field-label--type-inline'>Dry<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_97_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_97.3' type='checkbox'  value='Oily'  id='choice_5_97_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_97_3' id='label_5_97_3' class='gform-field-label gform-field-label--type-inline'>Oily<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_97_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_97.4' type='checkbox'  value='Combo Dry'  id='choice_5_97_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_97_4' id='label_5_97_4' class='gform-field-label gform-field-label--type-inline'>Combo Dry<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_97_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_97.5' type='checkbox'  value='Combo Oily'  id='choice_5_97_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_97_5' id='label_5_97_5' class='gform-field-label gform-field-label--type-inline'>Combo Oily<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_97_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_97.6' type='checkbox'  value='Acne Prone'  id='choice_5_97_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_97_6' id='label_5_97_6' class='gform-field-label gform-field-label--type-inline'>Acne Prone<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_97_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_97.7' type='checkbox'  value='Sensitive'  id='choice_5_97_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_97_7' id='label_5_97_7' class='gform-field-label gform-field-label--type-inline'>Sensitive<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_98\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_98\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What are your concerns today?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_98'><div class='gchoice gchoice_5_98_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.1' type='checkbox'  value='Uneven Skin Ton'  id='choice_5_98_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_98_1' id='label_5_98_1' class='gform-field-label gform-field-label--type-inline'>Uneven Skin Ton<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_98_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.2' type='checkbox'  value='Hyperpigmentation'  id='choice_5_98_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_98_2' id='label_5_98_2' class='gform-field-label gform-field-label--type-inline'>Hyperpigmentation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_98_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.3' type='checkbox'  value='Melasma'  id='choice_5_98_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_98_3' id='label_5_98_3' class='gform-field-label gform-field-label--type-inline'>Melasma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_98_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.4' type='checkbox'  value='Blackheads'  id='choice_5_98_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_98_4' id='label_5_98_4' class='gform-field-label gform-field-label--type-inline'>Blackheads<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_98_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.5' type='checkbox'  value='Acne'  id='choice_5_98_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_98_5' id='label_5_98_5' class='gform-field-label gform-field-label--type-inline'>Acne<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_98_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.6' type='checkbox'  value='Fine Lines'  id='choice_5_98_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_98_6' id='label_5_98_6' class='gform-field-label gform-field-label--type-inline'>Fine Lines<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_98_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.7' type='checkbox'  value='Wrinkles'  id='choice_5_98_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_98_7' id='label_5_98_7' class='gform-field-label gform-field-label--type-inline'>Wrinkles<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_98_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.8' type='checkbox'  value='Dull\/Dry Skin'  id='choice_5_98_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_98_8' id='label_5_98_8' class='gform-field-label gform-field-label--type-inline'>Dull\/Dry Skin<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_98_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.9' type='checkbox'  value='Rosacea'  id='choice_5_98_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_98_9' id='label_5_98_9' class='gform-field-label gform-field-label--type-inline'>Rosacea<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_98_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.11' type='checkbox'  value='Excessive Oil'  id='choice_5_98_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_98_11' id='label_5_98_11' class='gform-field-label gform-field-label--type-inline'>Excessive Oil<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_98_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.12' type='checkbox'  value='Dry Lips'  id='choice_5_98_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_98_12' id='label_5_98_12' class='gform-field-label gform-field-label--type-inline'>Dry Lips<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_98_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.13' type='checkbox'  value='Dark Circles'  id='choice_5_98_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_98_13' id='label_5_98_13' class='gform-field-label gform-field-label--type-inline'>Dark Circles<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_98_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.14' type='checkbox'  value='Relaxation'  id='choice_5_98_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_98_14' id='label_5_98_14' class='gform-field-label gform-field-label--type-inline'>Relaxation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_98_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.15' type='checkbox'  value='Stress Relief'  id='choice_5_98_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_98_15' id='label_5_98_15' class='gform-field-label gform-field-label--type-inline'>Stress Relief<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_65\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_65\" ><h3 class=\"gsection_title\">FEMALE GUESTS<\/h3><\/div><fieldset id=\"field_5_66\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_66\" ><legend class='gfield_label gform-field-label' >Are you pregnant or trying to get pregnant?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_66'>\n\t\t\t<div class='gchoice gchoice_5_66_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='Yes'  id='choice_5_66_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_66_0' id='label_5_66_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_66_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='No'  id='choice_5_66_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_66_1' id='label_5_66_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_30\" ><legend class='gfield_label gform-field-label' >Are you lactating?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_30'>\n\t\t\t<div class='gchoice gchoice_5_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Yes'  id='choice_5_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_30_0' id='label_5_30_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='No'  id='choice_5_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_30_1' id='label_5_30_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_67\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_67\" ><legend class='gfield_label gform-field-label' >Any recent changes to your contraceptive treatment?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_67'>\n\t\t\t<div class='gchoice gchoice_5_67_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='Yes'  id='choice_5_67_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_67_0' id='label_5_67_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_67_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='No'  id='choice_5_67_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_67_1' id='label_5_67_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_69\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_69\" ><label class='gfield_label gform-field-label' for='input_5_69'>If yes, list name of contraceptive<\/label><div class='ginput_container ginput_container_text'><input name='input_69' id='input_5_69' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_72\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_72\" ><legend class='gfield_label gform-field-label' >Are you taking oral contraceptives?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_72'>\n\t\t\t<div class='gchoice gchoice_5_72_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='Yes'  id='choice_5_72_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_72_0' id='label_5_72_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_72_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='No'  id='choice_5_72_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_72_1' id='label_5_72_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_49\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_49\" ><label class='gfield_label gform-field-label' for='input_5_49'>If yes, specify:<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_5_49' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_73\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_73\" ><legend class='gfield_label gform-field-label' >Are you going through menopause?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_73'>\n\t\t\t<div class='gchoice gchoice_5_73_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_73' type='radio' value='Yes'  id='choice_5_73_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_73_0' id='label_5_73_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_73_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_73' type='radio' value='No'  id='choice_5_73_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_73_1' id='label_5_73_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_74\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_74\" ><label class='gfield_label gform-field-label' for='input_5_74'>If yes, list any issues you are having since this hormonal change:<\/label><div class='ginput_container ginput_container_text'><input name='input_74' id='input_5_74' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_75\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_75\" ><h3 class=\"gsection_title\">MALE GUESTS<\/h3><\/div><fieldset id=\"field_5_33\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_33\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What is your current shaving system<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_33'><div class='gchoice gchoice_5_33_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.1' type='checkbox'  value='Wet shave'  id='choice_5_33_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_33_1' id='label_5_33_1' class='gform-field-label gform-field-label--type-inline'>Wet shave<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_33_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.2' type='checkbox'  value='Electric'  id='choice_5_33_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_33_2' id='label_5_33_2' class='gform-field-label gform-field-label--type-inline'>Electric<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_33_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.3' type='checkbox'  value='Disposable razor'  id='choice_5_33_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_33_3' id='label_5_33_3' class='gform-field-label gform-field-label--type-inline'>Disposable razor<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_33_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.4' type='checkbox'  value='Laser Hair Removal'  id='choice_5_33_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_33_4' id='label_5_33_4' class='gform-field-label gform-field-label--type-inline'>Laser Hair Removal<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_34\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_34\" ><legend class='gfield_label gform-field-label' >Do you experience irritation from shaving?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_34'>\n\t\t\t<div class='gchoice gchoice_5_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Yes'  id='choice_5_34_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_34_0' id='label_5_34_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='No'  id='choice_5_34_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_34_1' id='label_5_34_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_76\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_76\" ><legend class='gfield_label gform-field-label' >Do you get ingrown hairs after shaving?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_76'>\n\t\t\t<div class='gchoice gchoice_5_76_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Yes'  id='choice_5_76_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_76_0' id='label_5_76_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_76_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='No'  id='choice_5_76_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_76_1' id='label_5_76_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_41\" class=\"gfield gfield--type-consent gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_41\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_41.1' id='input_5_41_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_5_41\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_5_41_1' >I agree to the notice.<\/label><input type='hidden' name='input_41.2' value='I agree to the notice.' class='gform_hidden' \/><input type='hidden' name='input_41.3' value='2' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_5_41'>My signature below constitutes acknowledgement that I have read and understand the foregoing consent form and agree to the treatment. I consent to photographs being taken to evaluate treatment efficacy and for social media use. No photographs revealing my identity will be used without my written consent. I hold harmless LaVida Massage + Skincare, the Esthetician, and affiliates of all circumstances that may occur during my treatment. I agree that I am willing to follow recommendations by my Esthetician for home care. I will be responsible for following home regimens that can minimize or eliminate possible negative reactions, including recognizing the importance of adhering to sunscreen. If I may have additional questions or concerns regarding my treatment or suggested home product\/post-treatment care, I will consult my Esthetician immediately. I HEREBY AFFIRM:  I AM 18 YEARS OF AGE OR OLDER.  I HAVE CAREFULLY READ THIS DOCUMENT, AND I UNDERSTAND ITS CONTENTS.  I AM AWARE THIS DOCUMENT IS A RELEASE OF ALL LIABILITY AND A CONTRACT ENFORCEABLE AGAINST ME (AND MY HEIRS, NEXT OF KIN, DISTRIBUTEES, GUARDIANS, LEGAL REPRESENTATIVES, EXECUTORS, ADMINISTRATORS, SUCCESSORS AND ASSIGNS) IN A COURT OF LAW.  I HAVE SIGNED THIS DOCUMENT OF MY OWN FREE WILL.<\/div><\/fieldset><div id=\"field_5_42\" class=\"gfield gfield--type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_42\" ><label class='gfield_label gform-field-label' for='input_5_42'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_5_42_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_5_42_valid' id='input_5_42_valid' \/><canvas id='input_5_42' width='300' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_5_100\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_100\" ><label class='gfield_label gform-field-label' for='input_5_100'>Name<\/label><div class='ginput_container'><input name='input_100' id='input_5_100' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_5_100'>This field is for validation purposes and should be left unchanged.<\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_5' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' value='submit'  \/> <input type='hidden' name='gform_ajax' value='form_id=5&amp;title=1&amp;description=&amp;tabindex=0&amp;theme=gravity-theme&amp;hash=7d078ba33f732f8d9c03611f8a5e0953' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_5' 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