{"id":271508,"date":"2024-04-02T14:39:07","date_gmt":"2024-04-02T14:39:07","guid":{"rendered":"https:\/\/lavidamassagefortcollinsco.com\/?page_id=271508"},"modified":"2024-06-21T18:33:39","modified_gmt":"2024-06-21T18:33:39","slug":"returning-guest-intake-form","status":"publish","type":"page","link":"https:\/\/lavidamassagefortcollinsco.com\/forms\/returning-guest-intake-form\/","title":{"rendered":"Returning Guest 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; 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 and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var 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_12' >\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Returning Guest Intake Form<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_12'  action='\/wp-json\/wp\/v2\/pages\/271508' data-formid='12' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_12' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_12_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_12_1\" ><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_12_1'>\n                            \n                            <span id='input_12_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_12_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_12_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_12_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_12_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_12_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_12_3\" class=\"gfield gfield--type-phone gfield--input-type-phone 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_12_3\" ><label class='gfield_label gform-field-label' for='input_12_3'>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_3' id='input_12_3' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_19\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_12_19\" ><label class='gfield_label gform-field-label' for='input_12_19'>Date<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_12_19' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_12_5\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_12_5\" ><legend class='gfield_label gform-field-label' >Any changes to medical condtions:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_5'>\n\t\t\t<div class='gchoice gchoice_12_5_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='No'  id='choice_12_5_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_5_0' id='label_12_5_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_5_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='Yes'  id='choice_12_5_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_5_1' id='label_12_5_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_20\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_12_20\" ><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_12_20'><div class='gchoice gchoice_12_20_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.1' type='checkbox'  value='Warts'  id='choice_12_20_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_1' id='label_12_20_1' class='gform-field-label gform-field-label--type-inline'>Warts<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.2' type='checkbox'  value='Seizures'  id='choice_12_20_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_2' id='label_12_20_2' class='gform-field-label gform-field-label--type-inline'>Seizures<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.3' type='checkbox'  value='Varicose Veins'  id='choice_12_20_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_3' id='label_12_20_3' class='gform-field-label gform-field-label--type-inline'>Varicose Veins<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.4' type='checkbox'  value='Numbness\/Tingling'  id='choice_12_20_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_4' id='label_12_20_4' class='gform-field-label gform-field-label--type-inline'>Numbness\/Tingling<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.5' type='checkbox'  value='Birth Control Implant'  id='choice_12_20_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_5' id='label_12_20_5' class='gform-field-label gform-field-label--type-inline'>Birth Control Implant<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.6' type='checkbox'  value='Arthritis'  id='choice_12_20_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_6' id='label_12_20_6' class='gform-field-label gform-field-label--type-inline'>Arthritis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.7' type='checkbox'  value='Athletes Foot'  id='choice_12_20_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_7' id='label_12_20_7' class='gform-field-label gform-field-label--type-inline'>Athletes Foot<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.8' type='checkbox'  value='Blood Clots'  id='choice_12_20_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_8' id='label_12_20_8' class='gform-field-label gform-field-label--type-inline'>Blood Clots<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.9' type='checkbox'  value='Blood Pressure'  id='choice_12_20_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_9' id='label_12_20_9' class='gform-field-label gform-field-label--type-inline'>Blood Pressure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.11' type='checkbox'  value='Bruise Easily'  id='choice_12_20_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_11' id='label_12_20_11' class='gform-field-label gform-field-label--type-inline'>Bruise Easily<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.12' type='checkbox'  value='Cancer (active)'  id='choice_12_20_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_12' id='label_12_20_12' class='gform-field-label gform-field-label--type-inline'>Cancer (active)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.13' type='checkbox'  value='Diabetes'  id='choice_12_20_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_13' id='label_12_20_13' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.14' type='checkbox'  value='Fibromyalgia'  id='choice_12_20_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_14' id='label_12_20_14' class='gform-field-label gform-field-label--type-inline'>Fibromyalgia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.15' type='checkbox'  value='Headaches'  id='choice_12_20_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_15' id='label_12_20_15' class='gform-field-label gform-field-label--type-inline'>Headaches<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.16' type='checkbox'  value='Jaw Pain\/TMJ'  id='choice_12_20_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_16' id='label_12_20_16' class='gform-field-label gform-field-label--type-inline'>Jaw Pain\/TMJ<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.17' type='checkbox'  value='Leg or Knee Pain'  id='choice_12_20_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_17' id='label_12_20_17' class='gform-field-label gform-field-label--type-inline'>Leg or Knee Pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.18' type='checkbox'  value='Neck or Back'  id='choice_12_20_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_18' id='label_12_20_18' class='gform-field-label gform-field-label--type-inline'>Neck or Back<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.19' type='checkbox'  value='None'  id='choice_12_20_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_19' id='label_12_20_19' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.21' type='checkbox'  value='Other'  id='choice_12_20_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_21' id='label_12_20_21' 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_12_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_12_6\" ><label class='gfield_label gform-field-label' for='input_12_6'>If Other, please give detail<\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_12_6' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_12_7\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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_12_7\" ><legend class='gfield_label gform-field-label' >Any changes to allergies:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_7'>\n\t\t\t<div class='gchoice gchoice_12_7_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='No'  id='choice_12_7_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_7_0' id='label_12_7_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_7_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='Yes'  id='choice_12_7_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_7_1' id='label_12_7_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_8\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_12_8\" ><label class='gfield_label gform-field-label' for='input_12_8'>If yes, please give detail<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_12_8' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_12_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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_12_9\" ><legend class='gfield_label gform-field-label' >Any recent surgeries or injuries (last 2 year):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_9'>\n\t\t\t<div class='gchoice gchoice_12_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='No'  id='choice_12_9_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_9_0' id='label_12_9_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Yes'  id='choice_12_9_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_9_1' id='label_12_9_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_10\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_12_10\" ><label class='gfield_label gform-field-label' for='input_12_10'>If yes, please give detail<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_12_10' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_14\" class=\"gfield gfield--type-survey gfield--input-type-likert gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" data-js-reload=\"field_12_14\" ><label class='gfield_label gform-field-label' >Tell us about your current stress level<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_likert'><table aria-label='Tell us about your current stress level' class='gsurvey-likert' id='input_12_14'><thead><tr><th id='likert_col_1_12_14' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Completely Relaxed - 0<\/th><th id='likert_col_2_12_14' scope='col' role='presentation' class='gsurvey-likert-choice-label'>1<\/th><th id='likert_col_3_12_14' scope='col' role='presentation' class='gsurvey-likert-choice-label'>2<\/th><th id='likert_col_4_12_14' scope='col' role='presentation' class='gsurvey-likert-choice-label'>3<\/th><th id='likert_col_5_12_14' scope='col' role='presentation' class='gsurvey-likert-choice-label'>4<\/th><th id='likert_col_6_12_14' scope='col' role='presentation' class='gsurvey-likert-choice-label'>5<\/th><th id='likert_col_7_12_14' scope='col' role='presentation' class='gsurvey-likert-choice-label'>6<\/th><th id='likert_col_8_12_14' scope='col' role='presentation' class='gsurvey-likert-choice-label'>7<\/th><th id='likert_col_9_12_14' scope='col' role='presentation' class='gsurvey-likert-choice-label'>8<\/th><th id='likert_col_11_12_14' scope='col' role='presentation' class='gsurvey-likert-choice-label'>9<\/th><th id='likert_col_12_12_14' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Very Stressed - 10<\/th><\/tr><\/thead><tbody><tr><td data-label='Completely Relaxed - 0' class='gsurvey-likert-choice'><input name='input_14' type='radio' value='glikertcol14367e3a83'  id='choice_12_14_1'    aria-labelledby='likert_col_1_12_14'\/><\/td><td data-label='1' class='gsurvey-likert-choice'><input name='input_14' type='radio' value='glikertcol14a1c7df1e'  id='choice_12_14_2'    aria-labelledby='likert_col_2_12_14'\/><\/td><td data-label='2' class='gsurvey-likert-choice'><input name='input_14' type='radio' value='glikertcol14c10d7081'  id='choice_12_14_3'    aria-labelledby='likert_col_3_12_14'\/><\/td><td data-label='3' class='gsurvey-likert-choice'><input name='input_14' type='radio' value='glikertcol14433769ce'  id='choice_12_14_4'    aria-labelledby='likert_col_4_12_14'\/><\/td><td data-label='4' class='gsurvey-likert-choice'><input name='input_14' type='radio' value='glikertcol146fe9e0bb'  id='choice_12_14_5'    aria-labelledby='likert_col_5_12_14'\/><\/td><td data-label='5' class='gsurvey-likert-choice'><input name='input_14' type='radio' value='glikertcol14db941a74'  id='choice_12_14_6'    aria-labelledby='likert_col_6_12_14'\/><\/td><td data-label='6' class='gsurvey-likert-choice'><input name='input_14' type='radio' value='glikertcol1457926f1e'  id='choice_12_14_7'    aria-labelledby='likert_col_7_12_14'\/><\/td><td data-label='7' class='gsurvey-likert-choice'><input name='input_14' type='radio' value='glikertcol1479222bf1'  id='choice_12_14_8'    aria-labelledby='likert_col_8_12_14'\/><\/td><td data-label='8' class='gsurvey-likert-choice'><input name='input_14' type='radio' value='glikertcol147c664352'  id='choice_12_14_9'    aria-labelledby='likert_col_9_12_14'\/><\/td><td data-label='9' class='gsurvey-likert-choice'><input name='input_14' type='radio' value='glikertcol149cf9bf09'  id='choice_12_14_11'    aria-labelledby='likert_col_11_12_14'\/><\/td><td data-label='Very Stressed - 10' class='gsurvey-likert-choice'><input name='input_14' type='radio' value='glikertcol14bc20e27d'  id='choice_12_14_12'    aria-labelledby='likert_col_12_12_14'\/><\/td><\/tr><\/tbody><\/table><\/div><\/div><div id=\"field_12_15\" class=\"gfield gfield--type-survey gfield--input-type-likert gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" data-js-reload=\"field_12_15\" ><label class='gfield_label gform-field-label' >Tell us about your current pain level<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_likert'><table aria-label='Tell us about your current pain level' class='gsurvey-likert' id='input_12_15'><thead><tr><th id='likert_col_1_12_15' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Pain Free - 0<\/th><th id='likert_col_2_12_15' scope='col' role='presentation' class='gsurvey-likert-choice-label'>1<\/th><th id='likert_col_3_12_15' scope='col' role='presentation' class='gsurvey-likert-choice-label'>2<\/th><th id='likert_col_4_12_15' scope='col' role='presentation' class='gsurvey-likert-choice-label'>3<\/th><th id='likert_col_5_12_15' scope='col' role='presentation' class='gsurvey-likert-choice-label'>4<\/th><th id='likert_col_6_12_15' scope='col' role='presentation' class='gsurvey-likert-choice-label'>5<\/th><th id='likert_col_7_12_15' scope='col' role='presentation' class='gsurvey-likert-choice-label'>6<\/th><th id='likert_col_8_12_15' scope='col' role='presentation' class='gsurvey-likert-choice-label'>7<\/th><th id='likert_col_9_12_15' scope='col' role='presentation' class='gsurvey-likert-choice-label'>8<\/th><th id='likert_col_11_12_15' scope='col' role='presentation' class='gsurvey-likert-choice-label'>9<\/th><th id='likert_col_12_12_15' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Extreme Pain - 10<\/th><\/tr><\/thead><tbody><tr><td data-label='Pain Free - 0' class='gsurvey-likert-choice'><input name='input_15' type='radio' value='glikertcol14367e3a83'  id='choice_12_15_1'    aria-labelledby='likert_col_1_12_15'\/><\/td><td data-label='1' class='gsurvey-likert-choice'><input name='input_15' type='radio' value='glikertcol14a1c7df1e'  id='choice_12_15_2'    aria-labelledby='likert_col_2_12_15'\/><\/td><td data-label='2' class='gsurvey-likert-choice'><input name='input_15' type='radio' value='glikertcol14c10d7081'  id='choice_12_15_3'    aria-labelledby='likert_col_3_12_15'\/><\/td><td data-label='3' class='gsurvey-likert-choice'><input name='input_15' type='radio' value='glikertcol14433769ce'  id='choice_12_15_4'    aria-labelledby='likert_col_4_12_15'\/><\/td><td data-label='4' class='gsurvey-likert-choice'><input name='input_15' type='radio' value='glikertcol146fe9e0bb'  id='choice_12_15_5'    aria-labelledby='likert_col_5_12_15'\/><\/td><td data-label='5' class='gsurvey-likert-choice'><input name='input_15' type='radio' value='glikertcol14db941a74'  id='choice_12_15_6'    aria-labelledby='likert_col_6_12_15'\/><\/td><td data-label='6' class='gsurvey-likert-choice'><input name='input_15' type='radio' value='glikertcol1457926f1e'  id='choice_12_15_7'    aria-labelledby='likert_col_7_12_15'\/><\/td><td data-label='7' class='gsurvey-likert-choice'><input name='input_15' type='radio' value='glikertcol1479222bf1'  id='choice_12_15_8'    aria-labelledby='likert_col_8_12_15'\/><\/td><td data-label='8' class='gsurvey-likert-choice'><input name='input_15' type='radio' value='glikertcol147c664352'  id='choice_12_15_9'    aria-labelledby='likert_col_9_12_15'\/><\/td><td data-label='9' class='gsurvey-likert-choice'><input name='input_15' type='radio' value='glikertcol149cf9bf09'  id='choice_12_15_11'    aria-labelledby='likert_col_11_12_15'\/><\/td><td data-label='Extreme Pain - 10' class='gsurvey-likert-choice'><input name='input_15' type='radio' value='glikertcol14bc20e27d'  id='choice_12_15_12'    aria-labelledby='likert_col_12_12_15'\/><\/td><\/tr><\/tbody><\/table><\/div><\/div><div id=\"field_12_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_12_17\" ><b>IMPORTANT NOTICE:<\/b> If you have certain medical conditions or symptoms, receiving a massage may aggravate or worsen that condition. If you are experiencing a cold, flu, fever, or have consumed alcohol in the past 12 hours, your session must be rescheduled for 48 hours after symptoms disappear. By signing below, I am stating that I understand there are benefits and risks of massage therapy. I understand that massage is not a replacement for medical care, or medical examination. I acknowledge that any recommendation made by my massage therapist is not considered a medical diagnosis, or advice and that there is no stated promise of success of techniques, or services. I have listed all medical conditions (including past conditions, such as operations) that I am aware of and this information is true and accurate to the best of my knowledge. Before beginning a future session, I agree to inform the massage therapist immediately of any change in my health. I acknowledge that this information is confidential and intended for review by massage therapists, that a medical referral may be requested of me, and that LaVida Massage is not liable for the management of any condition whether it is identified or not on this form. This center location is independently owned.<\/div><fieldset id=\"field_12_16\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent 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_12_16\" ><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_16.1' id='input_12_16_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_12_16\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_12_16_1' >I agree to the privacy policy.<\/label><input type='hidden' name='input_16.2' value='I agree to the privacy policy.' class='gform_hidden' \/><input type='hidden' name='input_16.3' value='8' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_12_16'>I agree to inform my massage therapist of any discomfort or pain experienced during the session so any adjustments can be made to the pressure, draping or environment. LaVida Massage is not liable for any injury or condition that arises from the application of massage, despite the completion of this form. This form is only intended as an assessment tool and serves as a guide for the application of massage. All services include 5 minutes for pre-consultation and un-dressing and 5 minutes for post-consultation and re-dressing. I also understand that any illicit or  sexually suggestive remarks or advances, made by myself, will result in immediate termination of the session, and that I will be liable for full payment of the session. In compliance with Colorado state and federal law, LaVida Massage of Fort Collins considers gender of it's employees based on their gender identity and preferred gender pronouns.<br \/>\n<br \/>\nI affirm that I have read the important notice above before signing this document.<\/div><\/fieldset><div id=\"field_12_18\" class=\"gfield gfield--type-signature gfield--input-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_12_18\" ><label class='gfield_label gform-field-label' for='input_12_18'>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_12_18_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' 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novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_12' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_12_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_12_1\" ><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_12_1'>\n                            \n                            <span id='input_12_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_12_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_12_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_12_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_12_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_12_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_12_3\" class=\"gfield gfield--type-phone gfield--input-type-phone 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_12_3\" ><label class='gfield_label gform-field-label' for='input_12_3'>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_3' id='input_12_3' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_19\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_12_19\" ><label class='gfield_label gform-field-label' for='input_12_19'>Date<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_12_19' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_12_5\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_12_5\" ><legend class='gfield_label gform-field-label' >Any changes to medical condtions:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_5'>\n\t\t\t<div class='gchoice gchoice_12_5_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='No'  id='choice_12_5_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_5_0' id='label_12_5_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_5_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='Yes'  id='choice_12_5_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_5_1' id='label_12_5_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_20\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_12_20\" ><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_12_20'><div class='gchoice gchoice_12_20_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.1' type='checkbox'  value='Warts'  id='choice_12_20_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_1' id='label_12_20_1' class='gform-field-label gform-field-label--type-inline'>Warts<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.2' type='checkbox'  value='Seizures'  id='choice_12_20_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_2' id='label_12_20_2' class='gform-field-label gform-field-label--type-inline'>Seizures<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.3' type='checkbox'  value='Varicose Veins'  id='choice_12_20_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_3' id='label_12_20_3' class='gform-field-label gform-field-label--type-inline'>Varicose Veins<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.4' type='checkbox'  value='Numbness\/Tingling'  id='choice_12_20_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_4' id='label_12_20_4' class='gform-field-label gform-field-label--type-inline'>Numbness\/Tingling<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.5' type='checkbox'  value='Birth Control Implant'  id='choice_12_20_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_5' id='label_12_20_5' class='gform-field-label gform-field-label--type-inline'>Birth Control Implant<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.6' type='checkbox'  value='Arthritis'  id='choice_12_20_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_6' id='label_12_20_6' class='gform-field-label gform-field-label--type-inline'>Arthritis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.7' type='checkbox'  value='Athletes Foot'  id='choice_12_20_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_7' id='label_12_20_7' class='gform-field-label gform-field-label--type-inline'>Athletes Foot<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.8' type='checkbox'  value='Blood Clots'  id='choice_12_20_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_8' id='label_12_20_8' class='gform-field-label gform-field-label--type-inline'>Blood Clots<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.9' type='checkbox'  value='Blood Pressure'  id='choice_12_20_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_9' id='label_12_20_9' class='gform-field-label gform-field-label--type-inline'>Blood Pressure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.11' type='checkbox'  value='Bruise Easily'  id='choice_12_20_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_11' id='label_12_20_11' class='gform-field-label gform-field-label--type-inline'>Bruise Easily<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.12' type='checkbox'  value='Cancer (active)'  id='choice_12_20_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_12' id='label_12_20_12' class='gform-field-label gform-field-label--type-inline'>Cancer (active)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.13' type='checkbox'  value='Diabetes'  id='choice_12_20_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_13' id='label_12_20_13' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.14' type='checkbox'  value='Fibromyalgia'  id='choice_12_20_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_14' id='label_12_20_14' class='gform-field-label gform-field-label--type-inline'>Fibromyalgia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.15' type='checkbox'  value='Headaches'  id='choice_12_20_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_15' id='label_12_20_15' class='gform-field-label gform-field-label--type-inline'>Headaches<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.16' type='checkbox'  value='Jaw Pain\/TMJ'  id='choice_12_20_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_16' id='label_12_20_16' class='gform-field-label gform-field-label--type-inline'>Jaw Pain\/TMJ<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.17' type='checkbox'  value='Leg or Knee Pain'  id='choice_12_20_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_17' id='label_12_20_17' class='gform-field-label gform-field-label--type-inline'>Leg or Knee Pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.18' type='checkbox'  value='Neck or Back'  id='choice_12_20_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_18' id='label_12_20_18' class='gform-field-label gform-field-label--type-inline'>Neck or Back<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.19' type='checkbox'  value='None'  id='choice_12_20_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_19' id='label_12_20_19' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_20_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.21' type='checkbox'  value='Other'  id='choice_12_20_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_20_21' id='label_12_20_21' 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_12_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_12_6\" ><label class='gfield_label gform-field-label' for='input_12_6'>If Other, please give detail<\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_12_6' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_12_7\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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_12_7\" ><legend class='gfield_label gform-field-label' >Any changes to allergies:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_7'>\n\t\t\t<div class='gchoice gchoice_12_7_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='No'  id='choice_12_7_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_7_0' id='label_12_7_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_7_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='Yes'  id='choice_12_7_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_7_1' id='label_12_7_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_8\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_12_8\" ><label class='gfield_label gform-field-label' for='input_12_8'>If yes, please give detail<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_12_8' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_12_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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_12_9\" ><legend class='gfield_label gform-field-label' >Any recent surgeries or injuries (last 2 year):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_9'>\n\t\t\t<div class='gchoice gchoice_12_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='No'  id='choice_12_9_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_9_0' id='label_12_9_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Yes'  id='choice_12_9_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_9_1' id='label_12_9_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_10\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_12_10\" ><label class='gfield_label gform-field-label' for='input_12_10'>If yes, please give detail<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_12_10' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_14\" class=\"gfield gfield--type-survey gfield--input-type-likert gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" data-js-reload=\"field_12_14\" ><label class='gfield_label gform-field-label' >Tell us about your current stress level<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_likert'><table aria-label='Tell us about your current stress level' class='gsurvey-likert' id='input_12_14'><thead><tr><th id='likert_col_1_12_14' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Completely Relaxed - 0<\/th><th id='likert_col_2_12_14' scope='col' role='presentation' class='gsurvey-likert-choice-label'>1<\/th><th id='likert_col_3_12_14' scope='col' role='presentation' class='gsurvey-likert-choice-label'>2<\/th><th id='likert_col_4_12_14' scope='col' role='presentation' class='gsurvey-likert-choice-label'>3<\/th><th id='likert_col_5_12_14' scope='col' role='presentation' class='gsurvey-likert-choice-label'>4<\/th><th id='likert_col_6_12_14' scope='col' role='presentation' class='gsurvey-likert-choice-label'>5<\/th><th id='likert_col_7_12_14' scope='col' role='presentation' class='gsurvey-likert-choice-label'>6<\/th><th id='likert_col_8_12_14' scope='col' role='presentation' class='gsurvey-likert-choice-label'>7<\/th><th id='likert_col_9_12_14' scope='col' role='presentation' class='gsurvey-likert-choice-label'>8<\/th><th id='likert_col_11_12_14' scope='col' role='presentation' class='gsurvey-likert-choice-label'>9<\/th><th id='likert_col_12_12_14' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Very Stressed - 10<\/th><\/tr><\/thead><tbody><tr><td data-label='Completely Relaxed - 0' class='gsurvey-likert-choice'><input name='input_14' type='radio' value='glikertcol14367e3a83'  id='choice_12_14_1'    aria-labelledby='likert_col_1_12_14'\/><\/td><td data-label='1' class='gsurvey-likert-choice'><input name='input_14' type='radio' value='glikertcol14a1c7df1e'  id='choice_12_14_2'    aria-labelledby='likert_col_2_12_14'\/><\/td><td data-label='2' class='gsurvey-likert-choice'><input name='input_14' type='radio' value='glikertcol14c10d7081'  id='choice_12_14_3'    aria-labelledby='likert_col_3_12_14'\/><\/td><td data-label='3' class='gsurvey-likert-choice'><input name='input_14' type='radio' value='glikertcol14433769ce'  id='choice_12_14_4'    aria-labelledby='likert_col_4_12_14'\/><\/td><td data-label='4' class='gsurvey-likert-choice'><input name='input_14' type='radio' value='glikertcol146fe9e0bb'  id='choice_12_14_5'    aria-labelledby='likert_col_5_12_14'\/><\/td><td data-label='5' class='gsurvey-likert-choice'><input name='input_14' type='radio' value='glikertcol14db941a74'  id='choice_12_14_6'    aria-labelledby='likert_col_6_12_14'\/><\/td><td data-label='6' class='gsurvey-likert-choice'><input name='input_14' type='radio' value='glikertcol1457926f1e'  id='choice_12_14_7'    aria-labelledby='likert_col_7_12_14'\/><\/td><td data-label='7' class='gsurvey-likert-choice'><input name='input_14' type='radio' value='glikertcol1479222bf1'  id='choice_12_14_8'    aria-labelledby='likert_col_8_12_14'\/><\/td><td data-label='8' class='gsurvey-likert-choice'><input name='input_14' type='radio' value='glikertcol147c664352'  id='choice_12_14_9'    aria-labelledby='likert_col_9_12_14'\/><\/td><td data-label='9' class='gsurvey-likert-choice'><input name='input_14' type='radio' value='glikertcol149cf9bf09'  id='choice_12_14_11'    aria-labelledby='likert_col_11_12_14'\/><\/td><td data-label='Very Stressed - 10' class='gsurvey-likert-choice'><input name='input_14' type='radio' value='glikertcol14bc20e27d'  id='choice_12_14_12'    aria-labelledby='likert_col_12_12_14'\/><\/td><\/tr><\/tbody><\/table><\/div><\/div><div id=\"field_12_15\" class=\"gfield gfield--type-survey gfield--input-type-likert gfield--width-full gfield_contains_required field_sublabel_below 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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_12_17\" ><b>IMPORTANT NOTICE:<\/b> If you have certain medical conditions or symptoms, receiving a massage may aggravate or worsen that condition. If you are experiencing a cold, flu, fever, or have consumed alcohol in the past 12 hours, your session must be rescheduled for 48 hours after symptoms disappear. By signing below, I am stating that I understand there are benefits and risks of massage therapy. I understand that massage is not a replacement for medical care, or medical examination. I acknowledge that any recommendation made by my massage therapist is not considered a medical diagnosis, or advice and that there is no stated promise of success of techniques, or services. I have listed all medical conditions (including past conditions, such as operations) that I am aware of and this information is true and accurate to the best of my knowledge. Before beginning a future session, I agree to inform the massage therapist immediately of any change in my health. I acknowledge that this information is confidential and intended for review by massage therapists, that a medical referral may be requested of me, and that LaVida Massage is not liable for the management of any condition whether it is identified or not on this form. This center location is independently owned.<\/div><fieldset id=\"field_12_16\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent 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_12_16\" ><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_16.1' id='input_12_16_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_12_16\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_12_16_1' >I agree to the privacy policy.<\/label><input type='hidden' name='input_16.2' value='I agree to the privacy policy.' class='gform_hidden' \/><input type='hidden' name='input_16.3' value='8' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_12_16'>I agree to inform my massage therapist of any discomfort or pain experienced during the session so any adjustments can be made to the pressure, draping or environment. LaVida Massage is not liable for any injury or condition that arises from the application of massage, despite the completion of this form. This form is only intended as an assessment tool and serves as a guide for the application of massage. All services include 5 minutes for pre-consultation and un-dressing and 5 minutes for post-consultation and re-dressing. I also understand that any illicit or  sexually suggestive remarks or advances, made by myself, will result in immediate termination of the session, and that I will be liable for full payment of the session. In compliance with Colorado state and federal law, LaVida Massage of Fort Collins considers gender of it's employees based on their gender identity and preferred gender pronouns.<br \/>\n<br \/>\nI affirm that I have read the important notice above before signing this document.<\/div><\/fieldset><div id=\"field_12_18\" class=\"gfield gfield--type-signature gfield--input-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_12_18\" ><label class='gfield_label gform-field-label' for='input_12_18'>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_12_18_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' 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