{"id":271444,"date":"2024-02-23T19:44:12","date_gmt":"2024-02-23T19:44:12","guid":{"rendered":"https:\/\/lavidamassagefortcollinsco.com\/?page_id=271444"},"modified":"2024-03-26T17:09:29","modified_gmt":"2024-03-26T17:09:29","slug":"massage-intake-form","status":"publish","type":"page","link":"https:\/\/lavidamassagebrightonmi.com\/forms\/massage-intake-form\/","title":{"rendered":"Massage Intake Form"},"content":{"rendered":"<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 massage-intake-form_wrapper' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_5' style='display:none'><div id='gf_5' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_5' id='gform_5' class='massage-intake-form' action='\/wp-json\/wp\/v2\/pages\/271444#gf_5' data-formid='5' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_18\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_18\" ><h3 class=\"gsection_title\">Contact<\/h3><\/div><fieldset id=\"field_5_5\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_5\" ><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_5_5'>\n                            \n                            <span id='input_5_5_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.3' id='input_5_5_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_5_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_5_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.6' id='input_5_5_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_5_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_5_7\" class=\"gfield gfield--type-email 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_5_7\" ><label class='gfield_label gform-field-label' for='input_5_7'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_7' id='input_5_7' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_5_8\" class=\"gfield gfield--type-phone 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_5_8\" ><label class='gfield_label gform-field-label' for='input_5_8'>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_8' id='input_5_8' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_10\" class=\"gfield gfield--type-checkbox gfield--type-choice 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_5_10\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Phone Type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_10'><div class='gchoice gchoice_5_10_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.1' type='checkbox'  value='Home'  id='choice_5_10_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_10_1' id='label_5_10_1' class='gform-field-label gform-field-label--type-inline'>Home<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_10_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.2' type='checkbox'  value='Mobile'  id='choice_5_10_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_10_2' id='label_5_10_2' class='gform-field-label gform-field-label--type-inline'>Mobile<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_10_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.3' type='checkbox'  value='Work'  id='choice_5_10_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_10_3' id='label_5_10_3' class='gform-field-label gform-field-label--type-inline'>Work<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_10_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.4' type='checkbox'  value='Other'  id='choice_5_10_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_10_4' id='label_5_10_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_44\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_44\" ><legend class='gfield_label gform-field-label' >It&#039;s OK to text me!<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_44'>\n\t\t\t<div class='gchoice gchoice_5_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Yes'  id='choice_5_44_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_44_0' id='label_5_44_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_5_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='No'  id='choice_5_44_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_44_1' id='label_5_44_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_11\" class=\"gfield gfield--type-address 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_5_11\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_5_11' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_11_1_container' >\n                                        <input type='text' name='input_11.1' id='input_5_11_1' value=''    aria-required='true'    \/>\n                                        <label for='input_5_11_1' id='input_5_11_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_11_3_container' >\n                                    <input type='text' name='input_11.3' id='input_5_11_3' value=''    aria-required='true'    \/>\n                                    <label for='input_5_11_3' id='input_5_11_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_11_4_container' >\n                                        <select name='input_11.4' id='input_5_11_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_5_11_4' id='input_5_11_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_11_5_container' >\n                                    <input type='text' name='input_11.5' id='input_5_11_5' value=''    aria-required='true'    \/>\n                                    <label for='input_5_11_5' id='input_5_11_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_11.6' id='input_5_11_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_5_51\" class=\"gfield gfield--type-text 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_5_51\" ><label class='gfield_label gform-field-label' for='input_5_51'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_5_51' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_15\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_15\" ><label class='gfield_label gform-field-label' for='input_5_15'>Occupation<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_5_15' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_12\" class=\"gfield gfield--type-text 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_5_12\" ><label class='gfield_label gform-field-label' for='input_5_12'>Emergency Contact<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_5_12' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_13\" class=\"gfield gfield--type-phone 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_5_13\" ><label class='gfield_label gform-field-label' for='input_5_13'>Emergency Contact 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_13' id='input_5_13' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_14\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_14\" ><label class='gfield_label gform-field-label' for='input_5_14'>Emergency Contact Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_5_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_17\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_17\" ><h3 class=\"gsection_title\">History<\/h3><\/div><fieldset id=\"field_5_19\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_19\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >How did you hear about us?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_19'><div class='gchoice gchoice_5_19_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.1' type='checkbox'  value='Internet Search'  id='choice_5_19_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_19_1' id='label_5_19_1' class='gform-field-label gform-field-label--type-inline'>Internet Search<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_19_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.2' type='checkbox'  value='Email'  id='choice_5_19_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_19_2' id='label_5_19_2' class='gform-field-label gform-field-label--type-inline'>Email<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_19_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.3' type='checkbox'  value='Drive By\/Signs'  id='choice_5_19_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_19_3' id='label_5_19_3' class='gform-field-label gform-field-label--type-inline'>Drive By\/Signs<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_19_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.4' type='checkbox'  value='LaVida Massage Employee'  id='choice_5_19_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_19_4' id='label_5_19_4' class='gform-field-label gform-field-label--type-inline'>LaVida Massage Employee<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_19_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.5' type='checkbox'  value='Gift Cards'  id='choice_5_19_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_19_5' id='label_5_19_5' class='gform-field-label gform-field-label--type-inline'>Gift Cards<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_19_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.6' type='checkbox'  value='TV\/Radio'  id='choice_5_19_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_19_6' id='label_5_19_6' class='gform-field-label gform-field-label--type-inline'>TV\/Radio<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_19_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.7' type='checkbox'  value='Print Ad\/Magazine'  id='choice_5_19_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_19_7' id='label_5_19_7' class='gform-field-label gform-field-label--type-inline'>Print Ad\/Magazine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_19_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.8' type='checkbox'  value='LaVida Massage Client'  id='choice_5_19_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_19_8' id='label_5_19_8' class='gform-field-label gform-field-label--type-inline'>LaVida Massage Client<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_19_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.9' type='checkbox'  value='Other'  id='choice_5_19_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_19_9' id='label_5_19_9' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_20\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_20\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >How often do you receive professional massages?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_20'><div class='gchoice gchoice_5_20_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.1' type='checkbox'  value='First Time'  id='choice_5_20_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_20_1' id='label_5_20_1' class='gform-field-label gform-field-label--type-inline'>First Time<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_20_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.2' type='checkbox'  value='Once a year or less'  id='choice_5_20_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_20_2' id='label_5_20_2' class='gform-field-label gform-field-label--type-inline'>Once a year or less<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_20_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.3' type='checkbox'  value='2-3 times\/year'  id='choice_5_20_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_20_3' id='label_5_20_3' class='gform-field-label gform-field-label--type-inline'>2-3 times\/year<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_20_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.4' type='checkbox'  value='4-6 times\/yr'  id='choice_5_20_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_20_4' id='label_5_20_4' class='gform-field-label gform-field-label--type-inline'>4-6 times\/yr<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_20_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.5' type='checkbox'  value='7-10 times\/yr'  id='choice_5_20_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_20_5' id='label_5_20_5' class='gform-field-label gform-field-label--type-inline'>7-10 times\/yr<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_20_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.6' type='checkbox'  value='Monthly or more frequent'  id='choice_5_20_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_20_6' id='label_5_20_6' class='gform-field-label gform-field-label--type-inline'>Monthly or more frequent<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_21\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_21\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What prevents you from receiving massage for frequently?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_21'><div class='gchoice gchoice_5_21_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.1' type='checkbox'  value='Cost'  id='choice_5_21_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_21_1' id='label_5_21_1' class='gform-field-label gform-field-label--type-inline'>Cost<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_21_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.2' type='checkbox'  value='Time'  id='choice_5_21_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_21_2' id='label_5_21_2' class='gform-field-label gform-field-label--type-inline'>Time<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_21_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.3' type='checkbox'  value='Other'  id='choice_5_21_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_21_3' id='label_5_21_3' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_22\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_22\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Are you here today for:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_22'><div class='gchoice gchoice_5_22_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.1' type='checkbox'  value='Relaxation'  id='choice_5_22_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_22_1' id='label_5_22_1' class='gform-field-label gform-field-label--type-inline'>Relaxation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_22_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.2' type='checkbox'  value='Stress Relief'  id='choice_5_22_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_22_2' id='label_5_22_2' class='gform-field-label gform-field-label--type-inline'>Stress Relief<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_22_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.3' type='checkbox'  value='Soreness'  id='choice_5_22_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_22_3' id='label_5_22_3' class='gform-field-label gform-field-label--type-inline'>Soreness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_22_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.4' type='checkbox'  value='General Health &amp; Wellness'  id='choice_5_22_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_22_4' id='label_5_22_4' class='gform-field-label gform-field-label--type-inline'>General Health &amp; Wellness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_22_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.5' type='checkbox'  value='Headaches'  id='choice_5_22_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_22_5' id='label_5_22_5' class='gform-field-label gform-field-label--type-inline'>Headaches<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_22_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.6' type='checkbox'  value='Injury Rehab'  id='choice_5_22_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_22_6' id='label_5_22_6' class='gform-field-label gform-field-label--type-inline'>Injury Rehab<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_45\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_45\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >How often you would like to get a massage?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_45'><div class='gchoice gchoice_5_45_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.1' type='checkbox'  value='First Time'  id='choice_5_45_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_45_1' id='label_5_45_1' class='gform-field-label gform-field-label--type-inline'>First Time<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_45_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.2' type='checkbox'  value='Once a year or less'  id='choice_5_45_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_45_2' id='label_5_45_2' class='gform-field-label gform-field-label--type-inline'>Once a year or less<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_45_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.3' type='checkbox'  value='2-3 times\/year'  id='choice_5_45_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_45_3' id='label_5_45_3' class='gform-field-label gform-field-label--type-inline'>2-3 times\/year<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_45_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.4' type='checkbox'  value='4-6 times\/yr'  id='choice_5_45_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_45_4' id='label_5_45_4' class='gform-field-label gform-field-label--type-inline'>4-6 times\/yr<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_45_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.5' type='checkbox'  value='7-10 times\/yr'  id='choice_5_45_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_45_5' id='label_5_45_5' class='gform-field-label gform-field-label--type-inline'>7-10 times\/yr<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_45_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.6' type='checkbox'  value='Monthly or more frequent'  id='choice_5_45_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_45_6' id='label_5_45_6' class='gform-field-label gform-field-label--type-inline'>Monthly or more frequent<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_25\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_25\" ><label class='gfield_label gform-field-label' for='input_5_25'>Name of Referrer<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_5_25' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_26\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_26\" ><label class='gfield_label gform-field-label' for='input_5_26'>Other Description<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_5_26' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_27\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_27\" ><label class='gfield_label gform-field-label' for='input_5_27'>Other Description<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_5_27' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_23\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_23\" ><h3 class=\"gsection_title\">Medical Conditions<\/h3><\/div><fieldset id=\"field_5_24\" class=\"gfield gfield--type-checkbox gfield--type-choice 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_5_24\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Check all that apply<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_24'><div class='gchoice gchoice_5_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='Warts'  id='choice_5_24_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_1' id='label_5_24_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_5_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value='Seizures'  id='choice_5_24_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_2' id='label_5_24_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_5_24_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.3' type='checkbox'  value='Varicose Veins'  id='choice_5_24_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_3' id='label_5_24_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_5_24_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.4' type='checkbox'  value='Numbness\/Tingling'  id='choice_5_24_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_4' id='label_5_24_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_5_24_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.5' type='checkbox'  value='Birth Control Implant'  id='choice_5_24_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_5' id='label_5_24_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_5_24_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.6' type='checkbox'  value='Arthritis'  id='choice_5_24_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_6' id='label_5_24_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_5_24_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.7' type='checkbox'  value='Athletes Foot'  id='choice_5_24_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_7' id='label_5_24_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_5_24_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.8' type='checkbox'  value='Blood Clots'  id='choice_5_24_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_8' id='label_5_24_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_5_24_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.9' type='checkbox'  value='Blood Pressure'  id='choice_5_24_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_9' id='label_5_24_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_5_24_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.11' type='checkbox'  value='Bruise Easily'  id='choice_5_24_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_11' id='label_5_24_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_5_24_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.12' type='checkbox'  value='Cancer (active)'  id='choice_5_24_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_12' id='label_5_24_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_5_24_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.13' type='checkbox'  value='Diabetes'  id='choice_5_24_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_13' id='label_5_24_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_5_24_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.14' type='checkbox'  value='Fibromyalgia'  id='choice_5_24_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_14' id='label_5_24_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_5_24_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.15' type='checkbox'  value='Headaches'  id='choice_5_24_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_15' id='label_5_24_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_5_24_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.16' type='checkbox'  value='Jaw Pain\/TMJ'  id='choice_5_24_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_16' id='label_5_24_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_5_24_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.17' type='checkbox'  value='Leg or Knee Pain'  id='choice_5_24_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_17' id='label_5_24_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_5_24_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.18' type='checkbox'  value='Neck or Back'  id='choice_5_24_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_18' id='label_5_24_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_5_24_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.19' type='checkbox'  value='None'  id='choice_5_24_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_24_19' id='label_5_24_19' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_28\" class=\"gfield gfield--type-textarea 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_5_28\" ><label class='gfield_label gform-field-label' for='input_5_28'>Please list any medications you are taking<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_28' id='input_5_28' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_29\" class=\"gfield gfield--type-textarea 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_5_29\" ><label class='gfield_label gform-field-label' for='input_5_29'>Please list any other medical conditions<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_29' id='input_5_29' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_30\" class=\"gfield gfield--type-radio gfield--type-choice 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_5_30\" ><legend class='gfield_label gform-field-label' >Are you pregnant?<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_5_30'>\n\t\t\t<div class='gchoice gchoice_5_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='No'  id='choice_5_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_30_0' id='label_5_30_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_5_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Yes'  id='choice_5_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_30_1' id='label_5_30_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_31\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_31\" ><label class='gfield_label gform-field-label' for='input_5_31'>If yes, how many weeks?<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_5_31' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_33\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_33\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >If yes, are you experiencing any of the following?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_33'><div class='gchoice gchoice_5_33_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.1' type='checkbox'  value='Cramping\/Soreness'  id='choice_5_33_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_33_1' id='label_5_33_1' class='gform-field-label gform-field-label--type-inline'>Cramping\/Soreness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_33_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.2' type='checkbox'  value='Morning Sickness'  id='choice_5_33_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_33_2' id='label_5_33_2' class='gform-field-label gform-field-label--type-inline'>Morning Sickness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_33_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.3' type='checkbox'  value='Pre-Eclampsia'  id='choice_5_33_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_33_3' id='label_5_33_3' class='gform-field-label gform-field-label--type-inline'>Pre-Eclampsia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_33_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.4' type='checkbox'  value='Swelling (Edema)'  id='choice_5_33_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_33_4' id='label_5_33_4' class='gform-field-label gform-field-label--type-inline'>Swelling (Edema)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_49\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_49\" ><label class='gfield_label gform-field-label' for='input_5_49'>Due Date<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_5_49' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_34\" class=\"gfield gfield--type-radio gfield--type-choice 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_5_34\" ><legend class='gfield_label gform-field-label' >Do you have any allergies or skin sensitivities?<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_5_34'>\n\t\t\t<div class='gchoice gchoice_5_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='No'  id='choice_5_34_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_34_0' id='label_5_34_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_5_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Yes'  id='choice_5_34_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_34_1' id='label_5_34_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_35\" class=\"gfield gfield--type-textarea gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_35\" ><label class='gfield_label gform-field-label' for='input_5_35'>If yes, please list:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_35' id='input_5_35' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_37\" class=\"gfield gfield--type-radio gfield--type-choice 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_5_37\" ><legend class='gfield_label gform-field-label' >Our lotion products may contain nut oils. Are you allergic to nuts?<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_5_37'>\n\t\t\t<div class='gchoice gchoice_5_37_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='No'  id='choice_5_37_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_37_0' id='label_5_37_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_5_37_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Yes'  id='choice_5_37_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_37_1' id='label_5_37_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_36\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_36\" ><label class='gfield_label gform-field-label' for='input_5_36'>If yes, which nuts?<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_5_36' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_39\" class=\"gfield gfield--type-checkbox gfield--type-choice 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_5_39\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What areas would you like us to focus on today?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_39'><div class='gchoice gchoice_5_39_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.1' type='checkbox'  value='Right leg'  id='choice_5_39_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_39_1' id='label_5_39_1' class='gform-field-label gform-field-label--type-inline'>Right leg<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_39_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.2' type='checkbox'  value='Left leg'  id='choice_5_39_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_39_2' id='label_5_39_2' class='gform-field-label gform-field-label--type-inline'>Left leg<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_39_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.3' type='checkbox'  value='Right arm'  id='choice_5_39_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_39_3' id='label_5_39_3' class='gform-field-label gform-field-label--type-inline'>Right arm<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_39_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.4' type='checkbox'  value='Left arm'  id='choice_5_39_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_39_4' id='label_5_39_4' class='gform-field-label gform-field-label--type-inline'>Left arm<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_39_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.5' type='checkbox'  value='Neck'  id='choice_5_39_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_39_5' id='label_5_39_5' class='gform-field-label gform-field-label--type-inline'>Neck<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_39_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.6' type='checkbox'  value='Shoulders'  id='choice_5_39_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_39_6' id='label_5_39_6' class='gform-field-label gform-field-label--type-inline'>Shoulders<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_39_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.7' type='checkbox'  value='Back'  id='choice_5_39_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_39_7' id='label_5_39_7' class='gform-field-label gform-field-label--type-inline'>Back<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_39_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.8' type='checkbox'  value='Head'  id='choice_5_39_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_39_8' id='label_5_39_8' class='gform-field-label gform-field-label--type-inline'>Head<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_39_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.9' type='checkbox'  value='Right foot'  id='choice_5_39_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_39_9' id='label_5_39_9' class='gform-field-label gform-field-label--type-inline'>Right foot<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_39_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.11' type='checkbox'  value='Left foot'  id='choice_5_39_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_39_11' id='label_5_39_11' class='gform-field-label gform-field-label--type-inline'>Left foot<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_39_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.12' type='checkbox'  value='Glutes'  id='choice_5_39_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_39_12' id='label_5_39_12' class='gform-field-label gform-field-label--type-inline'>Glutes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_39_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.13' type='checkbox'  value='None'  id='choice_5_39_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_39_13' id='label_5_39_13' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_38\" class=\"gfield gfield--type-checkbox gfield--type-choice 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_5_38\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What areas would you like to avoid?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_38'><div class='gchoice gchoice_5_38_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.1' type='checkbox'  value='Right leg'  id='choice_5_38_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_38_1' id='label_5_38_1' class='gform-field-label gform-field-label--type-inline'>Right leg<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_38_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.2' type='checkbox'  value='Left leg'  id='choice_5_38_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_38_2' id='label_5_38_2' class='gform-field-label gform-field-label--type-inline'>Left leg<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_38_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.3' type='checkbox'  value='Right arm'  id='choice_5_38_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_38_3' id='label_5_38_3' class='gform-field-label gform-field-label--type-inline'>Right arm<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_38_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.4' type='checkbox'  value='Left arm'  id='choice_5_38_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_38_4' id='label_5_38_4' class='gform-field-label gform-field-label--type-inline'>Left arm<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_38_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.5' type='checkbox'  value='Neck'  id='choice_5_38_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_38_5' id='label_5_38_5' class='gform-field-label gform-field-label--type-inline'>Neck<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_38_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.6' type='checkbox'  value='Shoulders'  id='choice_5_38_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_38_6' id='label_5_38_6' class='gform-field-label gform-field-label--type-inline'>Shoulders<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_38_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.7' type='checkbox'  value='Back'  id='choice_5_38_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_38_7' id='label_5_38_7' class='gform-field-label gform-field-label--type-inline'>Back<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_38_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.8' type='checkbox'  value='Head'  id='choice_5_38_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_38_8' id='label_5_38_8' class='gform-field-label gform-field-label--type-inline'>Head<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_38_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.9' type='checkbox'  value='Right foot'  id='choice_5_38_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_38_9' id='label_5_38_9' class='gform-field-label gform-field-label--type-inline'>Right foot<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_38_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.11' type='checkbox'  value='Left foot'  id='choice_5_38_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_38_11' id='label_5_38_11' class='gform-field-label gform-field-label--type-inline'>Left foot<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_38_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.12' type='checkbox'  value='Glutes'  id='choice_5_38_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_38_12' id='label_5_38_12' class='gform-field-label gform-field-label--type-inline'>Glutes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_38_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.13' type='checkbox'  value='None'  id='choice_5_38_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_38_13' id='label_5_38_13' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_47\" 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_5_47\" ><label class='gfield_label gform-field-label' >Tell us about your current pain level. Check the number below:<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. Check the number below:' class='gsurvey-likert' id='input_5_47'><thead><tr><th id='likert_col_1_5_47' scope='col' role='presentation' class='gsurvey-likert-choice-label'>0 - Pain Free<\/th><th id='likert_col_2_5_47' scope='col' role='presentation' class='gsurvey-likert-choice-label'>1<\/th><th id='likert_col_3_5_47' scope='col' role='presentation' class='gsurvey-likert-choice-label'>2<\/th><th id='likert_col_4_5_47' scope='col' role='presentation' class='gsurvey-likert-choice-label'>3<\/th><th id='likert_col_5_5_47' scope='col' role='presentation' class='gsurvey-likert-choice-label'>4<\/th><th id='likert_col_6_5_47' scope='col' role='presentation' class='gsurvey-likert-choice-label'>5<\/th><th id='likert_col_7_5_47' scope='col' role='presentation' class='gsurvey-likert-choice-label'>6<\/th><th id='likert_col_8_5_47' scope='col' role='presentation' class='gsurvey-likert-choice-label'>7<\/th><th id='likert_col_9_5_47' scope='col' role='presentation' class='gsurvey-likert-choice-label'>8<\/th><th id='likert_col_11_5_47' scope='col' role='presentation' class='gsurvey-likert-choice-label'>9<\/th><th id='likert_col_12_5_47' scope='col' role='presentation' class='gsurvey-likert-choice-label'>10 - Extreme Pain<\/th><\/tr><\/thead><tbody><tr><td data-label='0 - Pain Free' class='gsurvey-likert-choice'><input name='input_47' type='radio' value='glikertcol47c8b01dea'  id='choice_5_47_1'    aria-labelledby='likert_col_1_5_47'\/><\/td><td data-label='1' class='gsurvey-likert-choice'><input name='input_47' type='radio' value='glikertcol47a9605dec'  id='choice_5_47_2'    aria-labelledby='likert_col_2_5_47'\/><\/td><td data-label='2' class='gsurvey-likert-choice'><input name='input_47' type='radio' value='glikertcol47cd13fb94'  id='choice_5_47_3'    aria-labelledby='likert_col_3_5_47'\/><\/td><td data-label='3' class='gsurvey-likert-choice'><input name='input_47' type='radio' value='glikertcol478607355d'  id='choice_5_47_4'    aria-labelledby='likert_col_4_5_47'\/><\/td><td data-label='4' class='gsurvey-likert-choice'><input name='input_47' type='radio' value='glikertcol47babeda08'  id='choice_5_47_5'    aria-labelledby='likert_col_5_5_47'\/><\/td><td data-label='5' class='gsurvey-likert-choice'><input name='input_47' type='radio' value='glikertcol47b72b5809'  id='choice_5_47_6'    aria-labelledby='likert_col_6_5_47'\/><\/td><td data-label='6' class='gsurvey-likert-choice'><input name='input_47' type='radio' value='glikertcol47e810461f'  id='choice_5_47_7'    aria-labelledby='likert_col_7_5_47'\/><\/td><td data-label='7' class='gsurvey-likert-choice'><input name='input_47' type='radio' value='glikertcol4789061c14'  id='choice_5_47_8'    aria-labelledby='likert_col_8_5_47'\/><\/td><td data-label='8' class='gsurvey-likert-choice'><input name='input_47' type='radio' value='glikertcol476cc08386'  id='choice_5_47_9'    aria-labelledby='likert_col_9_5_47'\/><\/td><td data-label='9' class='gsurvey-likert-choice'><input name='input_47' type='radio' value='glikertcol4703fdf5cc'  id='choice_5_47_11'    aria-labelledby='likert_col_11_5_47'\/><\/td><td data-label='10 - Extreme Pain' class='gsurvey-likert-choice'><input name='input_47' type='radio' value='glikertcol47ce17b9cd'  id='choice_5_47_12'    aria-labelledby='likert_col_12_5_47'\/><\/td><\/tr><\/tbody><\/table><\/div><\/div><div id=\"field_5_48\" 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_5_48\" ><label class='gfield_label gform-field-label' >Tell us about your current stress level. Check the number below:<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. Check the number below:' class='gsurvey-likert' id='input_5_48'><thead><tr><th id='likert_col_1_5_48' scope='col' role='presentation' class='gsurvey-likert-choice-label'>0 - Completely Relaxed<\/th><th id='likert_col_2_5_48' scope='col' role='presentation' class='gsurvey-likert-choice-label'>1<\/th><th id='likert_col_3_5_48' scope='col' role='presentation' class='gsurvey-likert-choice-label'>2<\/th><th id='likert_col_4_5_48' scope='col' role='presentation' class='gsurvey-likert-choice-label'>3<\/th><th id='likert_col_5_5_48' scope='col' role='presentation' class='gsurvey-likert-choice-label'>4<\/th><th id='likert_col_6_5_48' scope='col' role='presentation' class='gsurvey-likert-choice-label'>5<\/th><th id='likert_col_7_5_48' scope='col' role='presentation' class='gsurvey-likert-choice-label'>6<\/th><th id='likert_col_8_5_48' scope='col' role='presentation' class='gsurvey-likert-choice-label'>7<\/th><th id='likert_col_9_5_48' scope='col' role='presentation' class='gsurvey-likert-choice-label'>8<\/th><th id='likert_col_11_5_48' scope='col' role='presentation' class='gsurvey-likert-choice-label'>9<\/th><th id='likert_col_12_5_48' scope='col' role='presentation' class='gsurvey-likert-choice-label'>10 - Very Stressed<\/th><\/tr><\/thead><tbody><tr><td data-label='0 - Completely Relaxed' class='gsurvey-likert-choice'><input name='input_48' type='radio' value='glikertcol47c8b01dea'  id='choice_5_48_1'    aria-labelledby='likert_col_1_5_48'\/><\/td><td data-label='1' class='gsurvey-likert-choice'><input name='input_48' type='radio' value='glikertcol47a9605dec'  id='choice_5_48_2'    aria-labelledby='likert_col_2_5_48'\/><\/td><td data-label='2' class='gsurvey-likert-choice'><input name='input_48' type='radio' value='glikertcol47cd13fb94'  id='choice_5_48_3'    aria-labelledby='likert_col_3_5_48'\/><\/td><td data-label='3' class='gsurvey-likert-choice'><input name='input_48' type='radio' value='glikertcol478607355d'  id='choice_5_48_4'    aria-labelledby='likert_col_4_5_48'\/><\/td><td data-label='4' class='gsurvey-likert-choice'><input name='input_48' type='radio' value='glikertcol47babeda08'  id='choice_5_48_5'    aria-labelledby='likert_col_5_5_48'\/><\/td><td data-label='5' class='gsurvey-likert-choice'><input name='input_48' type='radio' value='glikertcol47b72b5809'  id='choice_5_48_6'    aria-labelledby='likert_col_6_5_48'\/><\/td><td data-label='6' class='gsurvey-likert-choice'><input name='input_48' type='radio' value='glikertcol47e810461f'  id='choice_5_48_7'    aria-labelledby='likert_col_7_5_48'\/><\/td><td data-label='7' class='gsurvey-likert-choice'><input name='input_48' type='radio' value='glikertcol4789061c14'  id='choice_5_48_8'    aria-labelledby='likert_col_8_5_48'\/><\/td><td data-label='8' class='gsurvey-likert-choice'><input name='input_48' type='radio' value='glikertcol476cc08386'  id='choice_5_48_9'    aria-labelledby='likert_col_9_5_48'\/><\/td><td data-label='9' class='gsurvey-likert-choice'><input name='input_48' type='radio' value='glikertcol4703fdf5cc'  id='choice_5_48_11'    aria-labelledby='likert_col_11_5_48'\/><\/td><td data-label='10 - Very Stressed' class='gsurvey-likert-choice'><input name='input_48' type='radio' value='glikertcol47ce17b9cd'  id='choice_5_48_12'    aria-labelledby='likert_col_12_5_48'\/><\/td><\/tr><\/tbody><\/table><\/div><\/div><fieldset id=\"field_5_41\" class=\"gfield gfield--type-consent gfield--type-choice 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_5_41\" ><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_41.1' id='input_5_41_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_5_41\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_5_41_1' >I agree to the notice.<\/label><input type='hidden' name='input_41.2' value='I agree to the notice.' class='gform_hidden' \/><input type='hidden' name='input_41.3' value='2' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_5_41'>IMPORTANT  NOTICE:  If  you  have  certain  medical  conditions  or  symptoms,  receiving  a  massage  may  aggravate  or  worsen  that   condition.  If  you  are  experiencing  a  cold,  fl  u,  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 benefi ts 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  confi  dential  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.<br \/>\n<br \/>\nI 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.<\/div><\/fieldset><div id=\"field_5_42\" class=\"gfield gfield--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_5_42\" ><label class='gfield_label gform-field-label' for='input_5_42'>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_5_42_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_5_42_valid' id='input_5_42_valid' \/><canvas id='input_5_42' width='300' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_5_52\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_52\" ><label class='gfield_label gform-field-label' for='input_5_52'>Name<\/label><div class='ginput_container'><input name='input_52' id='input_5_52' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_5_52'>This field is for validation purposes and should be left unchanged.<\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_5' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' value='submit'  \/> <input type='hidden' name='gform_ajax' value='form_id=5&amp;title=&amp;description=&amp;tabindex=0&amp;theme=gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_5' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_5' id='gform_theme_5' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_5' id='gform_style_settings_5' value='' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_5' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='5' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_5' 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