{"id":271472,"date":"2024-03-26T17:05:13","date_gmt":"2024-03-26T17:05:13","guid":{"rendered":"https:\/\/lavidamassagebrightonmi.com\/?page_id=271472"},"modified":"2024-03-26T17:10:14","modified_gmt":"2024-03-26T17:10:14","slug":"repeat-skincare-intake-form","status":"publish","type":"page","link":"https:\/\/lavidamassagebrightonmi.com\/forms\/repeat-skincare-intake-form\/","title":{"rendered":"Repeat Skincare 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 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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_4' style='display:none'><div id='gf_4' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_4' id='gform_4' class='massage-intake-form' action='\/wp-json\/wp\/v2\/pages\/271472#gf_4' data-formid='4' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_4_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_4_18\" ><h3 class=\"gsection_title\">Contact<\/h3><\/div><fieldset id=\"field_4_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_4_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_4_5'>\n                            \n                            <span id='input_4_5_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.3' id='input_4_5_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_4_5_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_4_5_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.6' id='input_4_5_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_4_5_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_4_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_4_7\" ><label class='gfield_label gform-field-label' for='input_4_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_4_7' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_4_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_4_8\" ><label class='gfield_label gform-field-label' for='input_4_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_4_8' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_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_4_17\" ><h3 class=\"gsection_title\">History<\/h3><\/div><div id=\"field_4_51\" 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_4_51\" ><label class='gfield_label gform-field-label' for='input_4_51'>When was your last chemical peel?<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_4_51' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_52\" 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_4_52\" ><label class='gfield_label gform-field-label' for='input_4_52'>When was your last facial?<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_4_52' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_53\" 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_4_53\" ><label class='gfield_label gform-field-label' for='input_4_53'>Date of last facial hair removal<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_4_53' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_54\" 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_4_54\" ><legend class='gfield_label gform-field-label' >Method of Removal<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_54'>\n\t\t\t<div class='gchoice gchoice_4_54_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Chemical Removal'  id='choice_4_54_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_54_0' id='label_4_54_0' class='gform-field-label gform-field-label--type-inline'>Chemical Removal<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_54_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Laser'  id='choice_4_54_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_54_1' id='label_4_54_1' class='gform-field-label gform-field-label--type-inline'>Laser<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_54_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Shaving'  id='choice_4_54_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_54_2' id='label_4_54_2' class='gform-field-label gform-field-label--type-inline'>Shaving<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_54_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Waxing'  id='choice_4_54_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_54_3' id='label_4_54_3' class='gform-field-label gform-field-label--type-inline'>Waxing<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_54_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Threading'  id='choice_4_54_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_54_4' id='label_4_54_4' class='gform-field-label gform-field-label--type-inline'>Threading<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_54_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='gf_other_choice'  id='choice_4_54_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_54_5' id='label_4_54_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_4_54_other' class='gchoice_other_control' name='input_54_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_101\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_101\" ><label class='gfield_label gform-field-label' for='input_4_101'>List any changes to your medical history since your last appointment:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_101' id='input_4_101' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_58\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_58\" ><legend class='gfield_label gform-field-label' >Do you have recent cosmetic injectables\/dermal fillers?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_58'>\n\t\t\t<div class='gchoice gchoice_4_58_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='Yes'  id='choice_4_58_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_58_0' id='label_4_58_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_4_58_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='No'  id='choice_4_58_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_58_1' id='label_4_58_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_61\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_61\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >If yes, which ones?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_61'><div class='gchoice gchoice_4_61_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.1' type='checkbox'  value='FBotox\/Xeomin\/Jeuveau'  id='choice_4_61_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_61_1' id='label_4_61_1' class='gform-field-label gform-field-label--type-inline'>FBotox\/Xeomin\/Jeuveau<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_61_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.2' type='checkbox'  value='PRP\/PRF'  id='choice_4_61_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_61_2' id='label_4_61_2' class='gform-field-label gform-field-label--type-inline'>PRP\/PRF<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_61_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.3' type='checkbox'  value='Vollure\/Voluma\/Volbella'  id='choice_4_61_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_61_3' id='label_4_61_3' class='gform-field-label gform-field-label--type-inline'>Vollure\/Voluma\/Volbella<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_61_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.4' type='checkbox'  value='Radiesse\/Sculptra'  id='choice_4_61_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_61_4' id='label_4_61_4' class='gform-field-label gform-field-label--type-inline'>Radiesse\/Sculptra<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_61_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.5' type='checkbox'  value='Other'  id='choice_4_61_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_61_5' id='label_4_61_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_25\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_4_25\" ><label class='gfield_label gform-field-label' for='input_4_25'>Date &amp; placement of most recent injection<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_4_25' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_102\" 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_4_102\" ><h3 class=\"gsection_title\">CONCERNS<\/h3><\/div><fieldset id=\"field_4_98\" 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_4_98\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What are your concerns today?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_98'><div class='gchoice gchoice_4_98_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.1' type='checkbox'  value='Uneven Skin Tone'  id='choice_4_98_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_98_1' id='label_4_98_1' class='gform-field-label gform-field-label--type-inline'>Uneven Skin Tone<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_98_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.2' type='checkbox'  value='Hyperpigmentation'  id='choice_4_98_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_98_2' id='label_4_98_2' class='gform-field-label gform-field-label--type-inline'>Hyperpigmentation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_98_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.3' type='checkbox'  value='Melasma'  id='choice_4_98_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_98_3' id='label_4_98_3' class='gform-field-label gform-field-label--type-inline'>Melasma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_98_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.4' type='checkbox'  value='Blackheads'  id='choice_4_98_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_98_4' id='label_4_98_4' class='gform-field-label gform-field-label--type-inline'>Blackheads<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_98_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.5' type='checkbox'  value='Acne'  id='choice_4_98_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_98_5' id='label_4_98_5' class='gform-field-label gform-field-label--type-inline'>Acne<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_98_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.6' type='checkbox'  value='Fine Lines'  id='choice_4_98_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_98_6' id='label_4_98_6' class='gform-field-label gform-field-label--type-inline'>Fine Lines<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_98_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.7' type='checkbox'  value='Wrinkles'  id='choice_4_98_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_98_7' id='label_4_98_7' class='gform-field-label gform-field-label--type-inline'>Wrinkles<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_98_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.8' type='checkbox'  value='Dull\/Dry Skin'  id='choice_4_98_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_98_8' id='label_4_98_8' class='gform-field-label gform-field-label--type-inline'>Dull\/Dry Skin<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_98_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.9' type='checkbox'  value='Rosacea'  id='choice_4_98_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_98_9' id='label_4_98_9' class='gform-field-label gform-field-label--type-inline'>Rosacea<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_98_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.11' type='checkbox'  value='Excessive Oil'  id='choice_4_98_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_98_11' id='label_4_98_11' class='gform-field-label gform-field-label--type-inline'>Excessive Oil<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_98_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.12' type='checkbox'  value='Dry Lips'  id='choice_4_98_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_98_12' id='label_4_98_12' class='gform-field-label gform-field-label--type-inline'>Dry Lips<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_98_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.13' type='checkbox'  value='Dark Circles'  id='choice_4_98_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_98_13' id='label_4_98_13' class='gform-field-label gform-field-label--type-inline'>Dark Circles<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_98_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.14' type='checkbox'  value='Relaxation'  id='choice_4_98_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_98_14' id='label_4_98_14' class='gform-field-label gform-field-label--type-inline'>Relaxation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_98_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.15' type='checkbox'  value='Stress Relief'  id='choice_4_98_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_98_15' id='label_4_98_15' class='gform-field-label gform-field-label--type-inline'>Stress Relief<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_88\" 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_4_88\" ><h3 class=\"gsection_title\">SKINCARE PRODUCTS YOU CURRENTLY USE DAILY\/WEEKLY<\/h3><\/div><div id=\"field_4_89\" 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_4_89\" ><label class='gfield_label gform-field-label' for='input_4_89'>Cleanser(s)<\/label><div class='ginput_container ginput_container_text'><input name='input_89' id='input_4_89' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_90\" 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_4_90\" ><label class='gfield_label gform-field-label' for='input_4_90'>Serums<\/label><div class='ginput_container ginput_container_text'><input name='input_90' id='input_4_90' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_91\" 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_4_91\" ><label class='gfield_label gform-field-label' for='input_4_91'>Toner<\/label><div class='ginput_container ginput_container_text'><input name='input_91' id='input_4_91' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_92\" 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_4_92\" ><label class='gfield_label gform-field-label' for='input_4_92'>Eye Serum\/Cream<\/label><div class='ginput_container ginput_container_text'><input name='input_92' id='input_4_92' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_93\" 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_4_93\" ><label class='gfield_label gform-field-label' for='input_4_93'>Exfoliant<\/label><div class='ginput_container ginput_container_text'><input name='input_93' id='input_4_93' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_94\" 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_4_94\" ><label class='gfield_label gform-field-label' for='input_4_94'>Moisturizer<\/label><div class='ginput_container ginput_container_text'><input name='input_94' id='input_4_94' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_95\" 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_4_95\" ><label class='gfield_label gform-field-label' for='input_4_95'>SPF<\/label><div class='ginput_container ginput_container_text'><input name='input_95' id='input_4_95' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_96\" 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_4_96\" ><label class='gfield_label gform-field-label' for='input_4_96'>Other<\/label><div class='ginput_container ginput_container_text'><input name='input_96' id='input_4_96' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_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_4_41\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >DISCLAIMER<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_4_41_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_4_41\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_4_41_1' >I agree<\/label><input type='hidden' name='input_41.2' value='I agree' class='gform_hidden' \/><input type='hidden' name='input_41.3' value='1' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_4_41'>I understand the treatment(s) I am about to receive is provided by a licensed Esthetician who has undergone all the current state, county, city, and educational requirements necessary to perform these treatments. If I notice discomfort, pain, etc., I will notify my Esthetician immediately. I understand that the application of glycolic acid can cause temporary redness, peeling and mild discomfort and I need to limit sun exposure and use broad spectrum sunscreen during treatment. I also understand my treatments are not to take the place of a doctor\u2019s examination, diagnosis, prescription, or treatment of a physical or mental illness or condition I knowingly or unknowingly currently have. I have to the best of my ability listed all known conditions, injuries, treatments, medications, past or present and hold LaVida Massage and its employees harmless for contraindications or injuries, whether physical or mental, by me not sharing my medical history. I agree to keep any Esthetician affiliated with LaVida Massage up to date on my health.<\/div><\/fieldset><div id=\"field_4_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_4_42\" ><label class='gfield_label gform-field-label' for='input_4_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_4_42_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_4_42_valid' id='input_4_42_valid' \/><canvas id='input_4_42' width='300' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_4_103\" class=\"gfield gfield--type-honeypot 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