{"id":271456,"date":"2024-02-23T19:51:19","date_gmt":"2024-02-23T19:51:19","guid":{"rendered":"https:\/\/lavidamassagefortcollinsco.com\/?page_id=271456"},"modified":"2024-06-21T18:30:12","modified_gmt":"2024-06-21T18:30:12","slug":"prenatal-consent-form","status":"publish","type":"page","link":"https:\/\/lavidamassagefortcollinsco.com\/forms\/prenatal-consent-form\/","title":{"rendered":"Prenatal Consent 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; custom_margin=&#8221;|0px||0px|false|false&#8221; custom_padding=&#8221;|0px||0px|false|false&#8221; hover_enabled=&#8221;0&#8243; global_colors_info=&#8221;{}&#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' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_8' ><div id='gf_8' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Prenatal Consent Form<\/h2>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_8' id='gform_8'  action='\/wp-json\/wp\/v2\/pages\/271456#gf_8' data-formid='8' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_8_1\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_1\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/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_8_1'>\n                            \n                            <span id='input_8_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_8_1_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_8_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_8_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_8_1_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_8_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_8_4\" class=\"gfield gfield--type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_4\" ><label class='gfield_label gform-field-label' for='input_8_4'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_8_4' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_3\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_3\" ><label class='gfield_label gform-field-label' for='input_8_3'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_3' id='input_8_3' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_8_3_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_8_3_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_8_3' class='gform_hidden' value='https:\/\/lavidamassagefortcollinsco.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_8_19\" class=\"gfield gfield--type-email gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_19\" ><label class='gfield_label gform-field-label' for='input_8_19'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_19' id='input_8_19' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_8_16\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_16\" ><label class='gfield_label gform-field-label' for='input_8_16'>Due Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_16' id='input_8_16' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_8_16_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_8_16_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_8_16' class='gform_hidden' value='https:\/\/lavidamassagefortcollinsco.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_8_17\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_17\" >Massage therapy during pregnancy has been shown to be beneficial for several common complaints such\nas fatigue, musculoskeletal pain, sciatica, and edema. However, there are risks associated with specific\nconditions that may occur during pregnancy. Below is a list of many symptoms or complications that can\noccur during pregnancy and may require the therapist to alter or cancel your session. You must also inform your massage therapist if you have or had any of the following \nconditions. Please check off any that may apply to your current or past pregnancies:<\/div><fieldset id=\"field_8_18\" 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_8_18\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Choose all that apply<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_8_18'><div class='gchoice gchoice_8_18_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.1' type='checkbox'  value='History of miscarriage'  id='choice_8_18_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_1' id='label_8_18_1' class='gform-field-label gform-field-label--type-inline'>History of miscarriage<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_18_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.2' type='checkbox'  value='Gestational Diabetes'  id='choice_8_18_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_2' id='label_8_18_2' class='gform-field-label gform-field-label--type-inline'>Gestational Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_18_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.3' type='checkbox'  value='Mother\u2019s age under 20 or over 40'  id='choice_8_18_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_3' id='label_8_18_3' class='gform-field-label gform-field-label--type-inline'>Mother\u2019s age under 20 or over 40<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_18_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.4' type='checkbox'  value='Pitting edema'  id='choice_8_18_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_4' id='label_8_18_4' class='gform-field-label gform-field-label--type-inline'>Pitting edema<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_18_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.5' type='checkbox'  value='Epilepsy or other convulsive disorders'  id='choice_8_18_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_5' id='label_8_18_5' class='gform-field-label gform-field-label--type-inline'>Epilepsy or other convulsive disorders<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_18_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.6' type='checkbox'  value='Placental or cervical dysfunction'  id='choice_8_18_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_6' id='label_8_18_6' class='gform-field-label gform-field-label--type-inline'>Placental or cervical dysfunction<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_18_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.7' type='checkbox'  value='Abdominal pain'  id='choice_8_18_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_7' id='label_8_18_7' class='gform-field-label gform-field-label--type-inline'>Abdominal pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_18_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.8' type='checkbox'  value='Leaking of amniotic fluid'  id='choice_8_18_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_8' id='label_8_18_8' class='gform-field-label gform-field-label--type-inline'>Leaking of amniotic fluid<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_18_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.9' type='checkbox'  value='Fever'  id='choice_8_18_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_9' id='label_8_18_9' class='gform-field-label gform-field-label--type-inline'>Fever<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_18_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.11' type='checkbox'  value='Sudden edema\/swelling'  id='choice_8_18_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_11' id='label_8_18_11' class='gform-field-label gform-field-label--type-inline'>Sudden edema\/swelling<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_18_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.12' type='checkbox'  value='Liver or renal disorders'  id='choice_8_18_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_12' id='label_8_18_12' class='gform-field-label gform-field-label--type-inline'>Liver or renal disorders<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_18_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.13' type='checkbox'  value='Severe headache'  id='choice_8_18_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_13' id='label_8_18_13' class='gform-field-label gform-field-label--type-inline'>Severe headache<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_18_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.14' type='checkbox'  value='Cardiac or pulmonary disorders'  id='choice_8_18_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_14' id='label_8_18_14' class='gform-field-label gform-field-label--type-inline'>Cardiac or pulmonary disorders<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_18_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.15' type='checkbox'  value='Preeclampsia'  id='choice_8_18_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_15' id='label_8_18_15' class='gform-field-label gform-field-label--type-inline'>Preeclampsia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_18_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.16' type='checkbox'  value='History of high-risk pregnancy'  id='choice_8_18_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_16' id='label_8_18_16' class='gform-field-label gform-field-label--type-inline'>History of high-risk pregnancy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_18_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.17' type='checkbox'  value='Current drug abuse'  id='choice_8_18_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_17' id='label_8_18_17' class='gform-field-label gform-field-label--type-inline'>Current drug abuse<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_18_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.18' type='checkbox'  value='History or multiples'  id='choice_8_18_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_18' id='label_8_18_18' class='gform-field-label gform-field-label--type-inline'>History or multiples<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_18_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.19' type='checkbox'  value='Fetal growth retardation'  id='choice_8_18_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_19' id='label_8_18_19' class='gform-field-label gform-field-label--type-inline'>Fetal growth retardation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_18_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.21' type='checkbox'  value='Diarrhea'  id='choice_8_18_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_21' id='label_8_18_21' class='gform-field-label gform-field-label--type-inline'>Diarrhea<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_18_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.22' type='checkbox'  value='Decrease in fetal movement'  id='choice_8_18_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_22' id='label_8_18_22' class='gform-field-label gform-field-label--type-inline'>Decrease in fetal movement<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_18_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.23' type='checkbox'  value='Severe nausea or vomiting'  id='choice_8_18_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_23' id='label_8_18_23' class='gform-field-label gform-field-label--type-inline'>Severe nausea or vomiting<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_15\" class=\"gfield gfield--type-consent gfield--type-choice gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_15\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Prenatal Massage Consent<\/legend><div class='ginput_container ginput_container_consent'><input name='input_15.1' id='input_8_15_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_8_15\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_8_15_1' >I agree<\/label><input type='hidden' name='input_15.2' value='I agree' class='gform_hidden' \/><input type='hidden' name='input_15.3' value='3' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_8_15'>I have read the above conditions and symptoms which may make massage therapy contraindicated. I have circled any of them that certain to me and\/or past experiences with pregnancy. I have disclosed all of my high-risk factors. I have discussed with my prenatal healthcare provider\/physician any health concerns that I had about receiving massage therapy. I agree that my healthcare provider\/physician has given me clearance to receive massage therapy. I understand the information contained on this form and am aware that I will be receiving massage therapy as an adjunct form of healthcare only. This therapy is not meant to replace appropriate medical care. I release LaVida Massage of Canton and the massage therapist of any and all liability for any harm that may unintentionally occur.<\/div><\/fieldset><div id=\"field_8_10\" class=\"gfield gfield--type-signature gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_10\" ><label class='gfield_label gform-field-label' for='input_8_10'>Signature<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_8_10_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_8_10_valid' id='input_8_10_valid' \/><canvas id='input_8_10' width='300' height='180'><\/canvas><\/div><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_8' class='gform_button button' 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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' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_8' ><div id='gf_8' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Prenatal Consent Form<\/h2>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_8' id='gform_8'  action='\/wp-json\/wp\/v2\/pages\/271456#gf_8' data-formid='8' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_8_1\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_1\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/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_8_1'>\n                            \n                            <span id='input_8_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_8_1_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_8_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_8_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_8_1_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_8_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_8_4\" class=\"gfield gfield--type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_4\" ><label class='gfield_label gform-field-label' for='input_8_4'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_8_4' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_3\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_3\" ><label class='gfield_label gform-field-label' for='input_8_3'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_3' id='input_8_3' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_8_3_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_8_3_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_8_3' class='gform_hidden' value='https:\/\/lavidamassagefortcollinsco.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_8_19\" class=\"gfield gfield--type-email gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_19\" ><label class='gfield_label gform-field-label' for='input_8_19'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_19' id='input_8_19' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_8_16\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_16\" ><label class='gfield_label gform-field-label' for='input_8_16'>Due Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_16' id='input_8_16' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_8_16_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_8_16_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_8_16' class='gform_hidden' value='https:\/\/lavidamassagefortcollinsco.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_8_17\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_17\" >Massage therapy during pregnancy has been shown to be beneficial for several common complaints such\nas fatigue, musculoskeletal pain, sciatica, and edema. However, there are risks associated with specific\nconditions that may occur during pregnancy. Below is a list of many symptoms or complications that can\noccur during pregnancy and may require the therapist to alter or cancel your session. You must also inform your massage therapist if you have or had any of the following \nconditions. Please check off any that may apply to your current or past pregnancies:<\/div><fieldset id=\"field_8_18\" 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_8_18\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Choose all that apply<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_8_18'><div class='gchoice gchoice_8_18_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.1' type='checkbox'  value='History of miscarriage'  id='choice_8_18_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_1' id='label_8_18_1' class='gform-field-label gform-field-label--type-inline'>History of miscarriage<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_18_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.2' type='checkbox'  value='Gestational Diabetes'  id='choice_8_18_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_2' id='label_8_18_2' class='gform-field-label gform-field-label--type-inline'>Gestational Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_18_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.3' type='checkbox'  value='Mother\u2019s age under 20 or over 40'  id='choice_8_18_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_3' id='label_8_18_3' class='gform-field-label gform-field-label--type-inline'>Mother\u2019s age under 20 or over 40<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_18_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.4' type='checkbox'  value='Pitting edema'  id='choice_8_18_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_4' id='label_8_18_4' class='gform-field-label gform-field-label--type-inline'>Pitting edema<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_18_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.5' type='checkbox'  value='Epilepsy or other convulsive disorders'  id='choice_8_18_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_5' id='label_8_18_5' class='gform-field-label gform-field-label--type-inline'>Epilepsy or other convulsive disorders<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_18_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.6' type='checkbox'  value='Placental or cervical dysfunction'  id='choice_8_18_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_6' id='label_8_18_6' class='gform-field-label gform-field-label--type-inline'>Placental or cervical dysfunction<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_18_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.7' type='checkbox'  value='Abdominal pain'  id='choice_8_18_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_7' id='label_8_18_7' class='gform-field-label gform-field-label--type-inline'>Abdominal pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_18_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.8' type='checkbox'  value='Leaking of amniotic fluid'  id='choice_8_18_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_8' id='label_8_18_8' class='gform-field-label gform-field-label--type-inline'>Leaking of amniotic fluid<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_18_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.9' type='checkbox'  value='Fever'  id='choice_8_18_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_9' id='label_8_18_9' class='gform-field-label gform-field-label--type-inline'>Fever<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_18_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.11' type='checkbox'  value='Sudden edema\/swelling'  id='choice_8_18_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_11' id='label_8_18_11' class='gform-field-label gform-field-label--type-inline'>Sudden edema\/swelling<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_18_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.12' type='checkbox'  value='Liver or renal disorders'  id='choice_8_18_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_12' id='label_8_18_12' class='gform-field-label gform-field-label--type-inline'>Liver or renal disorders<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_18_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.13' type='checkbox'  value='Severe headache'  id='choice_8_18_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_18_13' id='label_8_18_13' class='gform-field-label gform-field-label--type-inline'>Severe headache<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_18_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.14' type='checkbox'  value='Cardiac 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