{"id":1043,"date":"2024-02-27T17:54:11","date_gmt":"2024-02-27T17:54:11","guid":{"rendered":"https:\/\/skinretreattx.com\/?page_id=1043"},"modified":"2024-02-27T19:03:08","modified_gmt":"2024-02-27T19:03:08","slug":"skin-health-questionnaire","status":"publish","type":"page","link":"https:\/\/skinretreattx.com\/skin-health-questionnaire\/","title":{"rendered":"Skin Health Questionnaire"},"content":{"rendered":"<script type=\"text\/javascript\">var 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form_sublabel_below description_below'><div id=\"field_1_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_1\" ><label class='gfield_label gform-field-label' for='input_1_1'>Name<\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_1_1' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_2\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_2\" ><label class='gfield_label gform-field-label' for='input_1_2'>Date<\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_1_2' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_3\" ><label class='gfield_label gform-field-label' for='input_1_3'>Address<\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_1_3' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_4\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_4\" ><label class='gfield_label gform-field-label' for='input_1_4'>City<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_1_4' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_5\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_5\" ><label class='gfield_label gform-field-label' for='input_1_5'>State<\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_1_5' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_51\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_51\" ><label class='gfield_label gform-field-label' for='input_1_51'>Zip Code<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_1_51' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_6\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_6\" ><label class='gfield_label gform-field-label' for='input_1_6'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_6' id='input_1_6' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_7\" 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 gfield_visibility_visible\"  data-js-reload=\"field_1_7\" ><label class='gfield_label gform-field-label' for='input_1_7'>Birth Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_7' id='input_1_7' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_7_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_7_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_7' class='gform_hidden' value='https:\/\/skinretreattx.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_8\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_8\" ><label class='gfield_label gform-field-label' for='input_1_8'>Cellphone<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_1_8' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_10\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_10\" ><label class='gfield_label gform-field-label' for='input_1_10'>Other Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_1_10' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_9\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_9\" ><label class='gfield_label gform-field-label' for='input_1_9'>Occupation<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_1_9' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_11\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_11\" ><label class='gfield_label gform-field-label' for='input_1_11'>Current Skin Care<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_1_11' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_12\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_12\" ><label class='gfield_label gform-field-label' for='input_1_12'>Most Recent Facial<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_1_12' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_12\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_1_12'>Month\/Year<\/div><\/div><div id=\"field_1_13\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_13\" ><label class='gfield_label gform-field-label' for='input_1_13'>Most Recent Waxing<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_1_13' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_13\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_1_13'>Month\/Year<\/div><\/div><fieldset id=\"field_1_15\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_1_15\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >How do you feel about your skin?<\/legend><div class='gfield_description' id='gfield_description_1_15'>1 Poor &#8211; 10 Fantastic<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_15'><div class='gchoice gchoice_1_15_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.1' type='checkbox'  value='1'  id='choice_1_15_1'   aria-describedby=\"gfield_description_1_15\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_15_1' id='label_1_15_1' class='gform-field-label gform-field-label--type-inline'>1<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_15_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.2' type='checkbox'  value='2'  id='choice_1_15_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_15_2' id='label_1_15_2' class='gform-field-label gform-field-label--type-inline'>2<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_15_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.3' type='checkbox'  value='3'  id='choice_1_15_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_15_3' id='label_1_15_3' class='gform-field-label gform-field-label--type-inline'>3<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_15_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.4' type='checkbox'  value='4'  id='choice_1_15_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_15_4' id='label_1_15_4' class='gform-field-label gform-field-label--type-inline'>4<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_15_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.5' type='checkbox'  value='5'  id='choice_1_15_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_15_5' id='label_1_15_5' class='gform-field-label gform-field-label--type-inline'>5<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_15_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.6' type='checkbox'  value='6'  id='choice_1_15_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_15_6' id='label_1_15_6' class='gform-field-label gform-field-label--type-inline'>6<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_15_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.7' type='checkbox'  value='7'  id='choice_1_15_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_15_7' id='label_1_15_7' class='gform-field-label gform-field-label--type-inline'>7<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_15_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.8' type='checkbox'  value='8'  id='choice_1_15_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_15_8' id='label_1_15_8' class='gform-field-label gform-field-label--type-inline'>8<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_15_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.9' type='checkbox'  value='9'  id='choice_1_15_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_15_9' id='label_1_15_9' class='gform-field-label gform-field-label--type-inline'>9<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_15_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.11' type='checkbox'  value='10'  id='choice_1_15_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_15_11' id='label_1_15_11' class='gform-field-label gform-field-label--type-inline'>10<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_16\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_1_16\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Skin Conditions<\/legend><div class='gfield_description' id='gfield_description_1_16'>Check all that apply<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_16'><div class='gchoice gchoice_1_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='None'  id='choice_1_16_1'   aria-describedby=\"gfield_description_1_16\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_1' id='label_1_16_1' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.2' type='checkbox'  value='Wrinkles\/Fine Lines'  id='choice_1_16_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_2' id='label_1_16_2' class='gform-field-label gform-field-label--type-inline'>Wrinkles\/Fine Lines<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.3' type='checkbox'  value='Pigmentation'  id='choice_1_16_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_3' id='label_1_16_3' class='gform-field-label gform-field-label--type-inline'>Pigmentation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.4' type='checkbox'  value='Redness'  id='choice_1_16_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_4' id='label_1_16_4' class='gform-field-label gform-field-label--type-inline'>Redness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.5' type='checkbox'  value='Rosacea'  id='choice_1_16_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_5' id='label_1_16_5' class='gform-field-label gform-field-label--type-inline'>Rosacea<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.6' type='checkbox'  value='Dry\/Rough'  id='choice_1_16_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_6' id='label_1_16_6' class='gform-field-label gform-field-label--type-inline'>Dry\/Rough<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.7' type='checkbox'  value='Acne\/Oily'  id='choice_1_16_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_7' id='label_1_16_7' class='gform-field-label gform-field-label--type-inline'>Acne\/Oily<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_17\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_1_17\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Products Used Daily<\/legend><div class='gfield_description' id='gfield_description_1_17'>Check all that apply<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_17'><div class='gchoice gchoice_1_17_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.1' type='checkbox'  value='Cleanser'  id='choice_1_17_1'   aria-describedby=\"gfield_description_1_17\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_17_1' id='label_1_17_1' class='gform-field-label gform-field-label--type-inline'>Cleanser<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_17_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.2' type='checkbox'  value='Soap'  id='choice_1_17_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_17_2' id='label_1_17_2' class='gform-field-label gform-field-label--type-inline'>Soap<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_17_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.3' type='checkbox'  value='Exfoliator'  id='choice_1_17_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_17_3' id='label_1_17_3' class='gform-field-label gform-field-label--type-inline'>Exfoliator<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_17_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.4' type='checkbox'  value='Toner'  id='choice_1_17_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_17_4' id='label_1_17_4' class='gform-field-label gform-field-label--type-inline'>Toner<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_17_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.5' type='checkbox'  value='Moisturizer'  id='choice_1_17_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_17_5' id='label_1_17_5' class='gform-field-label gform-field-label--type-inline'>Moisturizer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_17_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.6' type='checkbox'  value='Sun Protection'  id='choice_1_17_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_17_6' id='label_1_17_6' class='gform-field-label gform-field-label--type-inline'>Sun Protection<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_17_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.7' type='checkbox'  value='Other Treatment'  id='choice_1_17_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_17_7' id='label_1_17_7' class='gform-field-label gform-field-label--type-inline'>Other Treatment<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_20\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_20\" ><h3>Lifestyle<\/h3><\/div><fieldset id=\"field_1_18\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_18\" ><legend class='gfield_label gform-field-label' >Do you use tanning booths\/beds?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_18'>\n\t\t\t<div class='gchoice gchoice_1_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Yes'  id='choice_1_18_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_18_0' id='label_1_18_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_1_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='No'  id='choice_1_18_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_18_1' id='label_1_18_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_21\" ><legend class='gfield_label gform-field-label' >Do you wax or use depilatories, electrolysis, or lasers for hair removal?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_21'>\n\t\t\t<div class='gchoice gchoice_1_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Yes'  id='choice_1_21_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_21_0' id='label_1_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_1_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='No'  id='choice_1_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_21_1' id='label_1_21_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_22\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_22\" ><legend class='gfield_label gform-field-label' >Do you have Botox, Restylane, Juv\u00e9derm or collagen injections?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_22'>\n\t\t\t<div class='gchoice gchoice_1_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Yes'  id='choice_1_22_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_22_0' id='label_1_22_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_1_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='No'  id='choice_1_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_22_1' id='label_1_22_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_48\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_48\" ><label class='gfield_label gform-field-label' for='input_1_48'>Last treatment?<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_1_48' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_23\" ><legend class='gfield_label gform-field-label' >Are you using exfoliating acids (glycolics)?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_23'>\n\t\t\t<div class='gchoice gchoice_1_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Yes'  id='choice_1_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_23_0' id='label_1_23_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_1_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='No'  id='choice_1_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_23_1' id='label_1_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_24\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_24\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Which ones?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_24'><div class='gchoice gchoice_1_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='Retin A'  id='choice_1_24_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_1' id='label_1_24_1' class='gform-field-label gform-field-label--type-inline'>Retin A<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value='Retinol'  id='choice_1_24_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_2' id='label_1_24_2' class='gform-field-label gform-field-label--type-inline'>Retinol<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.3' type='checkbox'  value='Glycolic'  id='choice_1_24_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_3' id='label_1_24_3' class='gform-field-label gform-field-label--type-inline'>Glycolic<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.4' type='checkbox'  value='Other'  id='choice_1_24_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_4' id='label_1_24_4' 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_1_25\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_25\" ><label class='gfield_label gform-field-label' for='input_1_25'>Other<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_1_25' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_26\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_26\" ><legend class='gfield_label gform-field-label' >Do you sunburn easily?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_26'>\n\t\t\t<div class='gchoice gchoice_1_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Yes'  id='choice_1_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_26_0' id='label_1_26_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_1_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='No'  id='choice_1_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_26_1' id='label_1_26_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_27\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_27\" ><label class='gfield_label gform-field-label' for='input_1_27'>Date of Last Sunburn<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_1_27' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_28\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_28\" ><legend class='gfield_label gform-field-label' >Do you smoke?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_28'>\n\t\t\t<div class='gchoice gchoice_1_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Yes'  id='choice_1_28_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_28_0' id='label_1_28_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_1_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='No'  id='choice_1_28_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_28_1' id='label_1_28_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_29\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_29\" ><label class='gfield_label gform-field-label' for='input_1_29'>How many ounces of water do you drink daily?<\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_1_29' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_30\" ><legend class='gfield_label gform-field-label' >Stress level<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_30'>\n\t\t\t<div class='gchoice gchoice_1_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='High'  id='choice_1_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_30_0' id='label_1_30_0' class='gform-field-label gform-field-label--type-inline'>High<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Average'  id='choice_1_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_30_1' id='label_1_30_1' class='gform-field-label gform-field-label--type-inline'>Average<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_30_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Low'  id='choice_1_30_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_30_2' id='label_1_30_2' class='gform-field-label gform-field-label--type-inline'>Low<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_31\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_31\" >Health History<\/div><div id=\"field_1_32\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_32\" ><label class='gfield_label gform-field-label' for='input_1_32'>List any allergies<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_1_32' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_33\" ><label class='gfield_label gform-field-label' for='input_1_33'>List current oral\/topical medications:<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_1_33' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_34\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_34\" ><legend class='gfield_label gform-field-label' >Have you recently had facial surgery or laser resurfacing?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_34'>\n\t\t\t<div class='gchoice gchoice_1_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Yes'  id='choice_1_34_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_34_0' id='label_1_34_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='No'  id='choice_1_34_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_34_1' id='label_1_34_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_35\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_35\" ><legend class='gfield_label gform-field-label' >Are you currently under the care of a dermatologist?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_35'>\n\t\t\t<div class='gchoice gchoice_1_35_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Yes'  id='choice_1_35_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_35_0' id='label_1_35_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_1_35_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='No'  id='choice_1_35_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_35_1' id='label_1_35_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_36\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_36\" ><label class='gfield_label gform-field-label' for='input_1_36'>If yes, please list name\/location<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_1_36' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_38\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_1_38\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Health Conditions<\/legend><div class='gfield_description' id='gfield_description_1_38'>Check all that apply<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_38'><div class='gchoice gchoice_1_38_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.1' type='checkbox'  value='Diabetes'  id='choice_1_38_1'   aria-describedby=\"gfield_description_1_38\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_1' id='label_1_38_1' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.2' type='checkbox'  value='Psoriasis'  id='choice_1_38_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_2' id='label_1_38_2' class='gform-field-label gform-field-label--type-inline'>Psoriasis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.3' type='checkbox'  value='Herpes'  id='choice_1_38_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_3' id='label_1_38_3' class='gform-field-label gform-field-label--type-inline'>Herpes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.4' type='checkbox'  value='Varicose Veins'  id='choice_1_38_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_4' id='label_1_38_4' 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_1_38_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.5' type='checkbox'  value='Chemotherapy'  id='choice_1_38_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_5' id='label_1_38_5' class='gform-field-label gform-field-label--type-inline'>Chemotherapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.6' type='checkbox'  value='Epilepsy'  id='choice_1_38_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_6' id='label_1_38_6' class='gform-field-label gform-field-label--type-inline'>Epilepsy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.7' type='checkbox'  value='Phlebitis'  id='choice_1_38_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_7' id='label_1_38_7' class='gform-field-label gform-field-label--type-inline'>Phlebitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.8' type='checkbox'  value='Eczema'  id='choice_1_38_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_8' id='label_1_38_8' class='gform-field-label gform-field-label--type-inline'>Eczema<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.9' type='checkbox'  value='Pacemaker'  id='choice_1_38_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_9' id='label_1_38_9' class='gform-field-label gform-field-label--type-inline'>Pacemaker<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.11' type='checkbox'  value='Cancer'  id='choice_1_38_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_11' id='label_1_38_11' class='gform-field-label gform-field-label--type-inline'>Cancer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.12' type='checkbox'  value='Retin A'  id='choice_1_38_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_12' id='label_1_38_12' class='gform-field-label gform-field-label--type-inline'>Retin A<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.13' type='checkbox'  value='Sunburn'  id='choice_1_38_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_13' id='label_1_38_13' class='gform-field-label gform-field-label--type-inline'>Sunburn<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.14' type='checkbox'  value='Hormone Pills'  id='choice_1_38_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_14' id='label_1_38_14' class='gform-field-label gform-field-label--type-inline'>Hormone Pills<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.15' type='checkbox'  value='Accutane'  id='choice_1_38_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_15' id='label_1_38_15' class='gform-field-label gform-field-label--type-inline'>Accutane<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.16' type='checkbox'  value='Contact lenses'  id='choice_1_38_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_16' id='label_1_38_16' class='gform-field-label gform-field-label--type-inline'>Contact lenses<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.17' type='checkbox'  value='Open Sores'  id='choice_1_38_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_17' id='label_1_38_17' class='gform-field-label gform-field-label--type-inline'>Open Sores<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.18' type='checkbox'  value='Pregnant'  id='choice_1_38_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_18' id='label_1_38_18' class='gform-field-label gform-field-label--type-inline'>Pregnant<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.19' type='checkbox'  value='Metal implants'  id='choice_1_38_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_19' id='label_1_38_19' class='gform-field-label gform-field-label--type-inline'>Metal implants<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_39\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_39\" ><label class='gfield_label gform-field-label' for='input_1_39'>Other health conditions of which we should be aware?<\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_1_39' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_45\" 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 gfield_visibility_visible\"  data-js-reload=\"field_1_45\" >Skin Retreat products and services are considered safe and involve minimal risk to our clients. Each Skin Retreat services involves applying a carefully selected product to your skin. Each products has been tested on humans to ensure it is safe. However, there is always a small risk of a mild reaction with any product. I UNDERSTAND AND VOLUNTARILY ACCEPT ANY RISKS ASSOCIATED WITH MY SERVICES AND THE USE OF THE SKIN RETREAT FACILILTY. I AGREE TO HOLD SKIN RETREAT HARMLESS FOR ANY INJURY, LOSS, CLAIMS AND DAMAGES, INCLUDING, WITHOUT LIMITATION, PERSONAL, BODILY, OR MENTAL INJURY, ECONOMIC LOSS, OR ANY DAMAGE TO ME RESULTING FROM MY RECEIPT OR USE OF THE SERVICES OR THE FACILITIES OF THE SPA.<\/div><div id=\"field_1_40\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_40\" ><label class='gfield_label gform-field-label' for='input_1_40'>I certify that I have given an honest and complete evaluation of my present physical condition.<\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_1_40' type='text' value='' class='small'  aria-describedby=\"gfield_description_1_40\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_1_40'>(Initial)<\/div><\/div><div id=\"field_1_42\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_42\" ><label class='gfield_label gform-field-label' for='input_1_42'>I will immediately notify my esthetician of any changes in my physical condition.<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_1_42' type='text' value='' class='small'  aria-describedby=\"gfield_description_1_42\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_1_42'>(Initial)<\/div><\/div><div id=\"field_1_44\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_44\" ><label class='gfield_label gform-field-label' for='input_1_44'>I understand that I may experience temporary redness or a cleansing breakout following my treatment.<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_1_44' type='text' value='' class='small'  aria-describedby=\"gfield_description_1_44\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_1_44'>(Initial)<\/div><\/div><div id=\"field_1_49\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_49\" ><label class='gfield_label gform-field-label' for='input_1_49'>Guest Signature<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_1_49_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_1_49_valid' id='input_1_49_valid' \/><canvas id='input_1_49' width='300' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_1_46\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_46\" ><label class='gfield_label gform-field-label' for='input_1_46'>Date Signed<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_46' id='input_1_46' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_46_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_46_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_46' class='gform_hidden' value='https:\/\/skinretreattx.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_50\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_50\" ><label class='gfield_label gform-field-label' for='input_1_50'>Parent\/Guardian Signature<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_1_50_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_1_50_valid' id='input_1_50_valid' \/><canvas id='input_1_50' width='300' height='180'><\/canvas><\/div><\/div><div class='gfield_description' id='gfield_description_1_50'>(if guest is a minor)<\/div><\/div><div id=\"field_1_47\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_47\" ><label class='gfield_label gform-field-label' for='input_1_47'>Date Signed<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_47' id='input_1_47' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_47_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_47_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_47' class='gform_hidden' value='https:\/\/skinretreattx.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><\/div><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_1' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  jQuery(\"#gform_1\").trigger(\"submit\",[true]); }' \/> \n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='1' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' 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