{"id":271470,"date":"2024-02-23T21:10:12","date_gmt":"2024-02-23T21:10:12","guid":{"rendered":"https:\/\/lavidamassagefortcollinsco.com\/?page_id=271470"},"modified":"2024-06-21T18:30:31","modified_gmt":"2024-06-21T18:30:31","slug":"pro-power-peel-consent-form","status":"publish","type":"page","link":"https:\/\/lavidamassagefortcollinsco.com\/forms\/pro-power-peel-consent-form\/","title":{"rendered":"Pro Power Peel 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 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Form<\/h2>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_11' id='gform_11'  action='\/wp-json\/wp\/v2\/pages\/271470#gf_11' data-formid='11' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_11' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_11_1\" class=\"gfield gfield--type-name gfield--input-type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_11_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_11_1'>\n                            \n                            <span 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       <\/div><\/fieldset><div id=\"field_11_4\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_11_4\" ><label class='gfield_label gform-field-label' for='input_11_4'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_11_4' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_3\" class=\"gfield gfield--type-date gfield--input-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_11_3\" ><label class='gfield_label gform-field-label' for='input_11_3'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_3' id='input_11_3' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_11_3_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_11_3_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_11_3' class='gform_hidden' value='https:\/\/lavidamassagefortcollinsco.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_11_17\" class=\"gfield gfield--type-html gfield--input-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_11_17\" >This treatment is designed to resurface the skin. You may experience temporary burning, itching, or stinging. Please inform your professional skin therapist if you experience these sensations. <p>\nYour full participation during and after the treatment will determine the outcome. It is important that you strictly adhere to the homecare products and regimen that your professional skin therapist has recommended. It is possible to have a poor reaction or less-than-expected improvement of the skin. No guarantee is made or implied as to the precise results, peeling times or discomfort. <\/div><fieldset id=\"field_11_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_11_21\" ><legend class='gfield_label gform-field-label' >Have you received a cosmetic light-based procedure such as laser treatment, IPL, etc. within the last 6 weeks?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_21'>\n\t\t\t<div class='gchoice gchoice_11_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Yes'  id='choice_11_21_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_21_0' id='label_11_21_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div 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class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_11_24\" ><legend class='gfield_label gform-field-label' >Do you experience redness, itching, or stinging on your skin?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_24'>\n\t\t\t<div class='gchoice gchoice_11_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Yes'  id='choice_11_24_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_24_0' id='label_11_24_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_11_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='No'  id='choice_11_24_1' onchange='gformToggleRadioOther( this 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name='input_15.3' value='7' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_11_15'>I release and waive any claims against Dermalogica, LLC and PSH Wellness and their affiliates and subsidiaries, and their respective officers, directors, agents, servants and employees, for any liability, demands, actions and causes of actions whatsoever arising out of or related to any loss, damage or injury that may be sustained by me while participating in the Pro Power Peel treatment, including, but not limited to, those injuries and damages caused by the negligence and or breach of warranty, express or implied, on the part of Dermalogica and\/or PSH Wellness. <br \/>\nI have received Post-Care instructional sheet. <\/div><\/fieldset><div id=\"field_11_10\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full field_sublabel_below gfield--no-description field_description_below 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current_page } } );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments;                var later = function() {                    timeout = null;                    if ( !immediate ) func.apply( context, args );                };                var callNow = immediate && !timeout;                clearTimeout( timeout );                timeout = setTimeout( later, wait );                if ( callNow ) func.apply( context, args );            };        }        const debouncedTriggerPostRender = debounce( function() {            triggerPostRender();        }, 200 );        if ( visibilityTestDiv && visibilityTestDiv.offsetParent === null ) {            const observer = new MutationObserver( ( mutations ) => {                mutations.forEach( ( 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              <h2 class=\"gform_title\">Pro Power Peel Consent Form<\/h2>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_11' id='gform_11'  action='\/wp-json\/wp\/v2\/pages\/271470#gf_11' data-formid='11' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_11' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_11_1\" class=\"gfield gfield--type-name gfield--input-type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_11_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_11_1'>\n                            \n                            <span id='input_11_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_11_1_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_11_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_11_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_11_1_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_11_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_11_4\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_11_4\" ><label class='gfield_label gform-field-label' for='input_11_4'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_11_4' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_3\" class=\"gfield gfield--type-date gfield--input-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_11_3\" ><label class='gfield_label gform-field-label' for='input_11_3'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_3' id='input_11_3' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_11_3_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_11_3_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_11_3' class='gform_hidden' value='https:\/\/lavidamassagefortcollinsco.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_11_17\" class=\"gfield gfield--type-html gfield--input-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_11_17\" >This treatment is designed to resurface the skin. You may experience temporary burning, itching, or stinging. Please inform your professional skin therapist if you experience these sensations. <p>\nYour full participation during and after the treatment will determine the outcome. It is important that you strictly adhere to the homecare products and regimen that your professional skin therapist has recommended. It is possible to have a poor reaction or less-than-expected improvement of the skin. No guarantee is made or implied as to the precise results, peeling times or discomfort. <\/div><fieldset id=\"field_11_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_11_21\" ><legend class='gfield_label gform-field-label' >Have you received a cosmetic light-based procedure such as laser treatment, IPL, etc. within the last 6 weeks?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_21'>\n\t\t\t<div class='gchoice gchoice_11_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Yes'  id='choice_11_21_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_21_0' id='label_11_21_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_11_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='No'  id='choice_11_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_21_1' id='label_11_21_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_20\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_11_20\" ><legend class='gfield_label gform-field-label' >Do you have active cold sores?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_20'>\n\t\t\t<div class='gchoice gchoice_11_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Yes'  id='choice_11_20_0' 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class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_11_24\" ><legend class='gfield_label gform-field-label' >Do you experience redness, itching, or stinging on your skin?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_24'>\n\t\t\t<div class='gchoice gchoice_11_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Yes'  id='choice_11_24_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_24_0' id='label_11_24_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_11_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='No'  id='choice_11_24_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_24_1' id='label_11_24_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_15\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_11_15\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<\/legend><div class='ginput_container ginput_container_consent'><input name='input_15.1' id='input_11_15_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_11_15\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_11_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='7' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_11_15'>I release and waive any claims against Dermalogica, LLC and PSH Wellness and their affiliates and subsidiaries, and their respective officers, directors, agents, servants and employees, for any liability, demands, actions and causes of actions whatsoever arising out of or related to any loss, damage or injury that may be sustained by me while participating in the Pro Power Peel treatment, including, but not limited to, those injuries and damages caused by the negligence and or breach of warranty, express or implied, on the part of Dermalogica and\/or PSH Wellness. <br \/>\nI have received Post-Care instructional sheet. <\/div><\/fieldset><div id=\"field_11_10\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full field_sublabel_below gfield--no-description field_description_below 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