{"id":1050,"date":"2024-03-05T01:24:01","date_gmt":"2024-03-05T01:24:01","guid":{"rendered":"https:\/\/skinretreattx.com\/?page_id=1050"},"modified":"2024-03-05T01:24:33","modified_gmt":"2024-03-05T01:24:33","slug":"advanced-services-consent-form","status":"publish","type":"page","link":"https:\/\/skinretreattx.com\/advanced-services-consent-form\/","title":{"rendered":"Advanced Services Consent Form"},"content":{"rendered":"<script type=\"text\/javascript\">var 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description_below validation_below'><div id=\"field_3_1\" 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 field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_1\" >For Chemical Peel, Microdermabrasion and Microcurrent clients:\n<ul>\n<li>The treatment you will receive is a clinical treatment designed to exfoliate or remove the outer layers of skin.<\/li>\n<li>We cannot guarantee precise results, peeling times, or level of discomfort. Your skin is unique to you!\n<\/li>\n<li>During the treatment, you may experience some temporary stinging, discomfort, or flushing of the skin.\n<\/li>\n<li>You may experience prolonged redness, irritation, dryness, or in rare instances, severe allergic reaction, scabbing, infection, eye injury, or scarring.\n<\/li>\n<li>For most peel clients, shedding of skin begins within 48 hours and usually subsides within 5\u20107 days.\n<\/li>\n<li>Your participation in your skin care helps determine the outcome. It is important that you follow the home care regimen, products, and timeline your esthetician has recommended. Skin Retreat offers the IMAGE Post Peel Treatment Kit, which contains all necessary products.\n<\/li>\n<li>Essential aftercare includes gentle manual cleansing of skin using a mild cleanser, application of moisturizer morning, night, and whenever skin feels tight or dry, and reapplication of SPF 30 or greater sunscreen throughout the day, as well as the professional advice of your esthetician, throughout the healing process. Avoid makeup on the day of your peel. Keep skin cool, with no heat\/hot water applied to the face and avoid strenuous exercise.<\/li>\n<\/ul><\/div><fieldset id=\"field_3_3\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_3\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >To receive Skin Retreat Advanced Services please initial as appropriate:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_3_3'><div class='gchoice gchoice_3_3_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.1' type='checkbox'  value='I have not used glycolic(s) for 24 hours.'  id='choice_3_3_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_3_1' id='label_3_3_1' class='gform-field-label gform-field-label--type-inline'>I have not used glycolic(s) for 24 hours.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_3_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.2' type='checkbox'  value='I have not used Retin\u2010A for 72 hours.'  id='choice_3_3_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_3_2' id='label_3_3_2' class='gform-field-label gform-field-label--type-inline'>I have not used Retin\u2010A for 72 hours.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_3_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.3' type='checkbox'  value='I have not had a Botox or collagen injection for 72 hrs. I have not taken Accutane in the past year.'  id='choice_3_3_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_3_3' id='label_3_3_3' class='gform-field-label gform-field-label--type-inline'>I have not had a Botox or collagen injection for 72 hrs. I have not taken Accutane in the past year.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_3_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.4' type='checkbox'  value='I do not have active cold sores.'  id='choice_3_3_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_3_4' id='label_3_3_4' class='gform-field-label gform-field-label--type-inline'>I do not have active cold sores.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_3_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.5' type='checkbox'  value='I have not received radiation treatments.'  id='choice_3_3_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_3_5' id='label_3_3_5' class='gform-field-label gform-field-label--type-inline'>I have not received radiation treatments.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_3_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.6' type='checkbox'  value='I am not allergic to aspirin.'  id='choice_3_3_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_3_6' id='label_3_3_6' class='gform-field-label gform-field-label--type-inline'>I am not allergic to aspirin.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_3_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.7' type='checkbox'  value='I understand there may be crusting &amp; shedding of skin following peels.'  id='choice_3_3_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_3_7' id='label_3_3_7' class='gform-field-label gform-field-label--type-inline'>I understand there may be crusting &amp; shedding of skin following peels.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_3_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.8' type='checkbox'  value='I agree not to pick, peel, or scratch healing skin.'  id='choice_3_3_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_3_8' id='label_3_3_8' class='gform-field-label gform-field-label--type-inline'>I agree not to pick, peel, or scratch healing skin.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_3_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.9' type='checkbox'  value='I agree to reapply sunscreen throughout the day.'  id='choice_3_3_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_3_9' id='label_3_3_9' class='gform-field-label gform-field-label--type-inline'>I agree to reapply sunscreen throughout the day.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_3_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.11' type='checkbox'  value='I agree not to wax for 7 days pre\/post treatment.'  id='choice_3_3_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_3_11' id='label_3_3_11' class='gform-field-label gform-field-label--type-inline'>I agree not to wax for 7 days pre\/post treatment.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_4\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_4\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >To receive Skin Retreat Advanced Services please initial as appropriate:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_3_4'><div class='gchoice gchoice_3_4_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.1' type='checkbox'  value='I agree to avoid direct sun exposure for 2 weeks.'  id='choice_3_4_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_4_1' id='label_3_4_1' class='gform-field-label gform-field-label--type-inline'>I agree to avoid direct sun exposure for 2 weeks.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_4_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.2' type='checkbox'  value='I agree not to tan for 30 days pre\/post peel.'  id='choice_3_4_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_4_2' id='label_3_4_2' class='gform-field-label gform-field-label--type-inline'>I agree not to tan for 30 days pre\/post peel.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_4_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.3' type='checkbox'  value='A peel patch test has been\/will be given to me.'  id='choice_3_4_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_4_3' id='label_3_4_3' class='gform-field-label gform-field-label--type-inline'>A peel patch test has been\/will be given to me.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_4_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.4' type='checkbox'  value='I do not have epilepsy or multiple sclerosis.'  id='choice_3_4_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_4_4' id='label_3_4_4' class='gform-field-label gform-field-label--type-inline'>I do not have epilepsy or multiple sclerosis.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_4_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.5' type='checkbox'  value='I am not currently using a pacemaker or defibrillator. I have no heart, muscular, or circulatory problems.'  id='choice_3_4_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_4_5' id='label_3_4_5' class='gform-field-label gform-field-label--type-inline'>I am not currently using a pacemaker or defibrillator. I have no heart, muscular, or circulatory problems.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_4_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.6' type='checkbox'  value='I do not have any metal implants, or a metal IUD.'  id='choice_3_4_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_4_6' id='label_3_4_6' class='gform-field-label gform-field-label--type-inline'>I do not have any metal implants, or a metal IUD.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_4_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.7' type='checkbox'  value='I agree to notify my esthetician of any concerns.'  id='choice_3_4_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_4_7' id='label_3_4_7' class='gform-field-label gform-field-label--type-inline'>I agree to notify my esthetician of any concerns.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_4_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.8' type='checkbox'  value='I agree to follow the home care product advice given by my esthetician.'  id='choice_3_4_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_4_8' id='label_3_4_8' class='gform-field-label gform-field-label--type-inline'>I agree to follow the home care product advice given by my esthetician.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_4_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.9' type='checkbox'  value='I am not pregnant. (If pregnant, please discuss treatment options with your esthetician.)'  id='choice_3_4_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_4_9' id='label_3_4_9' class='gform-field-label gform-field-label--type-inline'>I am not pregnant. (If pregnant, please discuss treatment options with your esthetician.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_4_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.11' type='checkbox'  value='If I am under the supervision of a physician I have discussed the treatment plan with him\/her.'  id='choice_3_4_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_4_11' id='label_3_4_11' class='gform-field-label gform-field-label--type-inline'>If I am under the supervision of a physician I have discussed the treatment plan with him\/her.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_4_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.12' type='checkbox'  value='The treatment was explained to me in detail.'  id='choice_3_4_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_4_12' id='label_3_4_12' class='gform-field-label gform-field-label--type-inline'>The treatment was explained to me in detail.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_5\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_5\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Acknowledgement<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_3_5'><div class='gchoice gchoice_3_5_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.1' type='checkbox'  value='The treatment procedure and benefits of what I can realistically treatment(s) have been fully explained to me.'  id='choice_3_5_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_5_1' id='label_3_5_1' class='gform-field-label gform-field-label--type-inline'>The treatment procedure and benefits of what I can realistically treatment(s) have been fully explained to me.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_6\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_6\" ><label class='gfield_label gform-field-label' for='input_3_6'>If you were unable to initial any of the above conditions, please explain.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_6' id='input_3_6' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_3_11\" 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 field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_11\" >HydraFacial is the only hydradermabrasion procedure that combines cleansing, exfoliation, extraction, hydration, and antioxidant protection simultaneously, resulting in clearer, more beautiful skin with little\u2010to\u2010no downtime. The treatment is soothing, moisturizing, non\u2010invasive and generally non\u2010irritating. As with most procedures, visible results from HydraFacial will vary from person to person. \nWhat to expect: <br><br>\n\n<ul><li>Your skin may experience temporary irritation, tightness, or redness. These are all normal reactions that typically resolve within 72 hours depending on skin sensitivity. <\/li>\n<li>You may experience tingling and stinging in the treatment area. These sensations generally subside within a few hours. \u2022 Client experiences may vary. Some clients may experience a delayed onset of these symptoms. \n <\/li>\n<li>You will likely see results immediately after treatment and your skin may feel smooth and hydrated for one to four weeks with appropriate home care to maintain treatment results. \n <\/li>\n<li>The skin is more susceptible to sunburn\/sun damage. Avoid excessive sun exposure and use a minimum of SPF 40 sunscreen. <\/li><\/ul><\/div><fieldset id=\"field_3_14\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_14\" ><legend class='gfield_label gform-field-label' >Active acne or infection?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_14'>\n\t\t\t<div class='gchoice gchoice_3_14_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Yes'  id='choice_3_14_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_14_0' id='label_3_14_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_3_14_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='No'  id='choice_3_14_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_14_1' id='label_3_14_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_15\" ><legend class='gfield_label gform-field-label' >Open lesion or cold sore?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_15'>\n\t\t\t<div class='gchoice gchoice_3_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Yes'  id='choice_3_15_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_15_0' id='label_3_15_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_3_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='No'  id='choice_3_15_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_15_1' id='label_3_15_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_12\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_12\" ><legend class='gfield_label gform-field-label' >An active infection in the treatment area?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_12'>\n\t\t\t<div class='gchoice gchoice_3_12_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Yes'  id='choice_3_12_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_12_0' id='label_3_12_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_3_12_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='No'  id='choice_3_12_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_12_1' id='label_3_12_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_16\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_16\" ><legend class='gfield_label gform-field-label' >Active sunburn?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_16'>\n\t\t\t<div class='gchoice gchoice_3_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Yes'  id='choice_3_16_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_16_0' id='label_3_16_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_3_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='No'  id='choice_3_16_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_16_1' id='label_3_16_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_17\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_17\" ><legend class='gfield_label gform-field-label' >Skin conditions such as eczema, dermatitis, or rashes?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_17'>\n\t\t\t<div class='gchoice gchoice_3_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Yes'  id='choice_3_17_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_17_0' id='label_3_17_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_3_17_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='No'  id='choice_3_17_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_17_1' id='label_3_17_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_13\" ><legend class='gfield_label gform-field-label' >An autoimmune disease such as lupus?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_13'>\n\t\t\t<div class='gchoice gchoice_3_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Yes'  id='choice_3_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_13_0' id='label_3_13_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_3_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='No'  id='choice_3_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_13_1' id='label_3_13_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_18\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_18\" ><legend class='gfield_label gform-field-label' >A viral concern such as HIV or hepatitis?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_18'>\n\t\t\t<div class='gchoice gchoice_3_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Yes'  id='choice_3_18_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_18_0' id='label_3_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_3_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='No'  id='choice_3_18_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_18_1' id='label_3_18_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_19\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_19\" ><legend class='gfield_label gform-field-label' >Anticoagulants Therapy?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_19'>\n\t\t\t<div class='gchoice gchoice_3_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Yes'  id='choice_3_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_19_0' id='label_3_19_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_3_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='No'  id='choice_3_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_19_1' id='label_3_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_20\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_20\" ><legend class='gfield_label gform-field-label' >Melanoma or lesions suspected of malignancy?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_20'>\n\t\t\t<div class='gchoice gchoice_3_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Yes'  id='choice_3_20_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_20_0' id='label_3_20_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_3_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='No'  id='choice_3_20_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_20_1' id='label_3_20_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_21\" ><legend class='gfield_label gform-field-label' >Pregnancy or lactation?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_21'>\n\t\t\t<div class='gchoice gchoice_3_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Yes'  id='choice_3_21_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_21_0' id='label_3_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_3_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='No'  id='choice_3_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_21_1' id='label_3_21_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_22\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_22\" ><legend class='gfield_label gform-field-label' >Neurological disorders such as epilepsy (LED Lights)?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_22'>\n\t\t\t<div class='gchoice gchoice_3_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Yes'  id='choice_3_22_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_22_0' id='label_3_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_3_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='No'  id='choice_3_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_22_1' id='label_3_22_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_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 field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_23\" ><legend class='gfield_label gform-field-label' >Infection in the urinary system i.e. kidneys, bladder and urethra (Lymphatic drainage)?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_23'>\n\t\t\t<div class='gchoice gchoice_3_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Yes'  id='choice_3_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_23_0' id='label_3_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_3_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='No'  id='choice_3_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_23_1' id='label_3_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_26\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_26\" ><legend class='gfield_label gform-field-label' >Hyperthyroidism(Lymphaticdrainage)?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_26'>\n\t\t\t<div class='gchoice gchoice_3_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Yes'  id='choice_3_26_0' onchange='gformToggleRadioOther( this )'    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