{"id":829,"date":"2025-08-20T08:35:33","date_gmt":"2025-08-20T13:35:33","guid":{"rendered":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/?page_id=829"},"modified":"2025-08-20T08:35:45","modified_gmt":"2025-08-20T13:35:45","slug":"uabstv-one-nineteen-spa-intake-form","status":"publish","type":"page","link":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/uabstv-one-nineteen-spa-intake-form\/","title":{"rendered":"UABSTV One Nineteen Spa Intake Form"},"content":{"rendered":"<script type=\"text\/javascript\">if(!gform){document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0});var gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),null==t&&(t=10),gform.hooks[o][n].push({tag:i,callable:r,priority:t})},doHook:function(o,n,r){if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[o][n]){var t,i=gform.hooks[o][n];i.sort(function(o,n){return o.priority-n.priority});for(var e=0;e<i.length;e++)\"function\"!=typeof(t=i[e].callable)&#038;&#038;(t=window[t]),\"action\"==o?t.apply(null,r):r[0]=t.apply(null,r)}if(\"filter\"==o)return r[0]},removeHook:function(o,n,r,t){if(null!=gform.hooks[o][n])for(var i=gform.hooks[o][n],e=i.length-1;0<=e;e--)null!=t&#038;&#038;t!=i[e].tag||null!=r&#038;&#038;r!=i[e].priority||i.splice(e,1)}}}<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme' id='gform_wrapper_223' style='display:none'><div id='gf_223' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_223' id='gform_223'  action='\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/pages\/829#gf_223' novalidate>\n        <div id='gf_progressbar_wrapper_223' class='gf_progressbar_wrapper'>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>2<\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_custom' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_custom percentbar_50' style='width:50%; color:; background-color:#00a99e;'><span>50%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform_body gform-body'><div id='gform_page_223_1' class='gform_page' >\n                                    <div class='gform_page_fields'><div id='gform_fields_223' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_223_2\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_223_2' >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_2' id='input_223_2' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_223_3\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_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 no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_223_3'>\n                            \n                            <span id='input_223_3_3_container' class='name_first' >\n                                                    <input type='text' name='input_3.3' id='input_223_3_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_223_3_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_223_3_6_container' class='name_last' >\n                                                    <input type='text' name='input_3.6' id='input_223_3_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_223_3_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_223_4\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_223_4' >Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_4' id='input_223_4' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_223_4_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_223_4_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_223_4' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_223_5\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_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_street2 has_city has_state has_zip ginput_container_address' id='input_223_5' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_223_5_1_container' >\n                                        <input type='text' name='input_5.1' id='input_223_5_1' value=''    aria-required='true'    \/>\n                                        <label for='input_223_5_1' id='input_223_5_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_223_5_2_container' >\n                                        <input type='text' name='input_5.2' id='input_223_5_2' value=''     aria-required='false'   \/>\n                                        <label for='input_223_5_2' id='input_223_5_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_223_5_3_container' >\n                                    <input type='text' name='input_5.3' id='input_223_5_3' value=''    aria-required='true'    \/>\n                                    <label for='input_223_5_3' id='input_223_5_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_223_5_4_container' >\n                                        <select name='input_5.4' id='input_223_5_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/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='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='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/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='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_223_5_4' id='input_223_5_4_label' >State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_223_5_5_container' >\n                                    <input type='text' name='input_5.5' id='input_223_5_5' value=''    aria-required='true'    \/>\n                                    <label for='input_223_5_5' id='input_223_5_5_label' >ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_5.6' id='input_223_5_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_223_6\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_223_6' >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_6' id='input_223_6' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_223_7\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_223_7' >Please select your service<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_7' id='input_223_7' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Massage' >Massage<\/option><option value='Facial' >Facial<\/option><\/select><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_223_1' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_223\").val(\"2\");  jQuery(\"#gform_223\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_223\").val(\"2\");  jQuery(\"#gform_223\").trigger(\"submit\",[true]); } ' \/> <button type='button'  id='gform_save_223_2_link' class='gform_save_link button'  onclick='if(window[\"gf_submitting_223\"]){return false;}  if( !jQuery(\"#gform_223\")[0].checkValidity || jQuery(\"#gform_223\")[0].checkValidity()){window[\"gf_submitting_223\"]=true;} jQuery(\"#gform_save_223\").val(1); jQuery(\"#gform_223\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_223\"]){return false;} if( !jQuery(\"#gform_223\")[0].checkValidity || jQuery(\"#gform_223\")[0].checkValidity()){window[\"gf_submitting_223\"]=true;} jQuery(\"#gform_save_223\").val(1); jQuery(\"#gform_223\").trigger(\"submit\",[true]); }'><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_223_2' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_223_2' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_223_8\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_223_8' >Occupation<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_223_8' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_223_9\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_223_9' >Who should we thank for referring you today?<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_223_9' type='text' value='' class='large'  aria-describedby=\"gfield_description_223_9\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_223_9'>Existing clients who refer 4 new clients to Spa One Nineteen, receive 1 FREE massage of equal or lessor value.  Ask your service provider how to benefit from this referral program.<\/div><\/div><fieldset id=\"field_223_10\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >How did you hear about us?<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_223_10'><div class='gchoice gchoice_223_10_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.1' type='checkbox'  value='Facebook'  id='choice_223_10_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_10_1' id='label_223_10_1'>Facebook<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_10_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.2' type='checkbox'  value='Twitter'  id='choice_223_10_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_10_2' id='label_223_10_2'>Twitter<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_10_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.3' type='checkbox'  value='E-Blast'  id='choice_223_10_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_10_3' id='label_223_10_3'>E-Blast<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_10_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.4' type='checkbox'  value='New Member'  id='choice_223_10_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_10_4' id='label_223_10_4'>New Member<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_10_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.5' type='checkbox'  value='In facility for another reason'  id='choice_223_10_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_10_5' id='label_223_10_5'>In facility for another reason<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_10_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.6' type='checkbox'  value='Radio'  id='choice_223_10_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_10_6' id='label_223_10_6'>Radio<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_10_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.7' type='checkbox'  value='Website'  id='choice_223_10_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_10_7' id='label_223_10_7'>Website<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_10_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.8' type='checkbox'  value='Word of Mouth'  id='choice_223_10_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_10_8' id='label_223_10_8'>Word of Mouth<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_10_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.9' type='checkbox'  value='Associate'  id='choice_223_10_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_10_9' id='label_223_10_9'>Associate<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_10_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.11' type='checkbox'  value='Other'  id='choice_223_10_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_10_11' id='label_223_10_11'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_223_11\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_223_11' >Other<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_223_11' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_223_13\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Are you currently under a physicians care?<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_223_13'>\n\t\t\t<div class='gchoice gchoice_223_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Yes'  id='choice_223_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_223_13_0' id='label_223_13_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_223_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='No'  id='choice_223_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_223_13_1' id='label_223_13_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_223_14\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_223_14' >If yes, please explain<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_14' id='input_223_14' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_223_16\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Please check the following that are applicable<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_223_16'><div class='gchoice gchoice_223_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='Blood Clots or suspicion of Blood Clots'  id='choice_223_16_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_1' id='label_223_16_1'>Blood Clots or suspicion of Blood Clots<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.2' type='checkbox'  value='Cancer'  id='choice_223_16_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_2' id='label_223_16_2'>Cancer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.3' type='checkbox'  value='Allergies'  id='choice_223_16_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_3' id='label_223_16_3'>Allergies<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.4' type='checkbox'  value='Aids\/HIV'  id='choice_223_16_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_4' id='label_223_16_4'>Aids\/HIV<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.5' type='checkbox'  value='Asthma'  id='choice_223_16_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_5' id='label_223_16_5'>Asthma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.6' type='checkbox'  value='Tuberculosis'  id='choice_223_16_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_6' id='label_223_16_6'>Tuberculosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.7' type='checkbox'  value='Diabetes'  id='choice_223_16_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_7' id='label_223_16_7'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.8' type='checkbox'  value='Epilepsy'  id='choice_223_16_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_8' id='label_223_16_8'>Epilepsy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.9' type='checkbox'  value='Heart Attack'  id='choice_223_16_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_9' id='label_223_16_9'>Heart Attack<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.11' type='checkbox'  value='Hepatitis'  id='choice_223_16_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_11' id='label_223_16_11'>Hepatitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.12' type='checkbox'  value='Immune Compromised'  id='choice_223_16_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_12' id='label_223_16_12'>Immune Compromised<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.13' type='checkbox'  value='Kidney Disease'  id='choice_223_16_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_13' id='label_223_16_13'>Kidney Disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.14' type='checkbox'  value='Shingles'  id='choice_223_16_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_14' id='label_223_16_14'>Shingles<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.15' type='checkbox'  value='Metal Implants'  id='choice_223_16_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_15' id='label_223_16_15'>Metal Implants<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.16' type='checkbox'  value='Neurological Disease'  id='choice_223_16_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_16' id='label_223_16_16'>Neurological Disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.17' type='checkbox'  value='Nail Fungus'  id='choice_223_16_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_17' id='label_223_16_17'>Nail Fungus<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.18' type='checkbox'  value='Blood Circulation'  id='choice_223_16_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_18' id='label_223_16_18'>Blood Circulation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.19' type='checkbox'  value='Keloid Scarring'  id='choice_223_16_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_19' id='label_223_16_19'>Keloid Scarring<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.21' type='checkbox'  value='Decreased Range of Motion'  id='choice_223_16_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_21' id='label_223_16_21'>Decreased Range of Motion<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.22' type='checkbox'  value='Neck Pain'  id='choice_223_16_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_22' id='label_223_16_22'>Neck Pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.23' type='checkbox'  value='Whiplash'  id='choice_223_16_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_23' id='label_223_16_23'>Whiplash<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.24' type='checkbox'  value='Headaches'  id='choice_223_16_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_24' id='label_223_16_24'>Headaches<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.25' type='checkbox'  value='Disk Problems'  id='choice_223_16_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_25' id='label_223_16_25'>Disk Problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.26' type='checkbox'  value='Surgery'  id='choice_223_16_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_26' id='label_223_16_26'>Surgery<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.27' type='checkbox'  value='High\/Low Blood Pressure'  id='choice_223_16_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_27' id='label_223_16_27'>High\/Low Blood Pressure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.28' type='checkbox'  value='Herpes\/Cold Sores'  id='choice_223_16_28'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_28' id='label_223_16_28'>Herpes\/Cold Sores<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_29'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.29' type='checkbox'  value='Sinus Problems'  id='choice_223_16_29'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_29' id='label_223_16_29'>Sinus Problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_31'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.31' type='checkbox'  value='Mid Back Pain'  id='choice_223_16_31'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_31' id='label_223_16_31'>Mid Back Pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_32'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.32' type='checkbox'  value='Sprains'  id='choice_223_16_32'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_32' id='label_223_16_32'>Sprains<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_33'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.33' type='checkbox'  value='Low Back Pain'  id='choice_223_16_33'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_33' id='label_223_16_33'>Low Back Pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_34'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.34' type='checkbox'  value='Seizures'  id='choice_223_16_34'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_34' id='label_223_16_34'>Seizures<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_35'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.35' type='checkbox'  value='Serious Injury'  id='choice_223_16_35'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_35' id='label_223_16_35'>Serious Injury<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_36'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.36' type='checkbox'  value='Abdominal Pain'  id='choice_223_16_36'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_36' id='label_223_16_36'>Abdominal Pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_37'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.37' type='checkbox'  value='Nervous Tension'  id='choice_223_16_37'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_37' id='label_223_16_37'>Nervous Tension<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_38'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.38' type='checkbox'  value='Arthritis, Bursitis'  id='choice_223_16_38'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_38' id='label_223_16_38'>Arthritis, Bursitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_39'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.39' type='checkbox'  value='Joint Pain'  id='choice_223_16_39'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_39' id='label_223_16_39'>Joint Pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_41'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.41' type='checkbox'  value='Varicose Veins'  id='choice_223_16_41'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_41' id='label_223_16_41'>Varicose Veins<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_42'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.42' type='checkbox'  value='Broken Bones'  id='choice_223_16_42'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_42' id='label_223_16_42'>Broken Bones<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_43'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.43' type='checkbox'  value='Hormone Imbalance'  id='choice_223_16_43'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_43' id='label_223_16_43'>Hormone Imbalance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_16_44'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.44' type='checkbox'  value='Pregnant: By checking this, I am verifying I am at least 12 weeks along'  id='choice_223_16_44'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_16_44' id='label_223_16_44'>Pregnant: By checking this, I am verifying I am at least 12 weeks along<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_223_17\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_223_17' >List all medications, vitamins, and drugs you are taking and reason<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_223_17' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_223_18\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_223_18' >What is the reason for your visit today?<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_223_18' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_223_19\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Any specific skin challenges<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_223_19'><div class='gchoice gchoice_223_19_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.1' type='checkbox'  value='Flaking'  id='choice_223_19_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_19_1' id='label_223_19_1'>Flaking<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_19_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.2' type='checkbox'  value='Tightness'  id='choice_223_19_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_19_2' id='label_223_19_2'>Tightness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_19_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.3' type='checkbox'  value='Sunburn'  id='choice_223_19_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_19_3' id='label_223_19_3'>Sunburn<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_19_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.4' type='checkbox'  value='Eczema'  id='choice_223_19_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_19_4' id='label_223_19_4'>Eczema<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_19_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.5' type='checkbox'  value='None'  id='choice_223_19_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_19_5' id='label_223_19_5'>None<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_19_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.6' type='checkbox'  value='Other'  id='choice_223_19_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_19_6' id='label_223_19_6'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_223_20\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_223_20' >Other<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_20' id='input_223_20' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_223_22\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_223_22' >Have you ever had a reaction to any treatments?<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_22' id='input_223_22' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_223_23\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_223_23' >By digitally signing this intake form, I agree to the UAB St. Vincent&#039;s One Nineteen Spa cancelation policy.  I recognize that if I cancel within 24 hours of my service, it will be marked as a missed appointment.  I am allowed 3 missed services per calendar year.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div ><div id='input_223_23_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_223_23_valid' id='input_223_23_valid' \/><canvas id='input_223_23' width='300' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_223_24\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Tell us a little about your skin<\/h3><\/div><fieldset id=\"field_223_25\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Does your occupation require you to work outdoors?<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_223_25'>\n\t\t\t<div class='gchoice gchoice_223_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Yes'  id='choice_223_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_223_25_0' id='label_223_25_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_223_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='No'  id='choice_223_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_223_25_1' id='label_223_25_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_223_26\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Which of the following best describes your skin type<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_223_26'>\n\t\t\t<div class='gchoice gchoice_223_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='(Skin type I) Creamy Complexion - Always burns easy, never tans'  id='choice_223_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_223_26_0' id='label_223_26_0'>(Skin type I) Creamy Complexion - Always burns easy, never tans<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_223_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='(Skin type II) Light Complexion - Always burns, tans minimally'  id='choice_223_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_223_26_1' id='label_223_26_1'>(Skin type II) Light Complexion - Always burns, tans minimally<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_223_26_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='(Skin type III) Light\/Matte Complexion - Burns moderately, tans gradually'  id='choice_223_26_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_223_26_2' id='label_223_26_2'>(Skin type III) Light\/Matte Complexion - Burns moderately, tans gradually<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_223_26_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='(Skin type IV) Moderate Complexion - Seldom burns, always tans well'  id='choice_223_26_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_223_26_3' id='label_223_26_3'>(Skin type IV) Moderate Complexion - Seldom burns, always tans well<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_223_26_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='(Skin type V) Deep Complexion - Rarely burns, tans easily'  id='choice_223_26_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_223_26_4' id='label_223_26_4'>(Skin type V) Deep Complexion - Rarely burns, tans easily<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_223_26_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='(Skin type VI) Dark Complexion - Never burns, deeply pigmented'  id='choice_223_26_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_223_26_5' id='label_223_26_5'>(Skin type VI) Dark Complexion - Never burns, deeply pigmented<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_223_27\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Have you received a facial treatment before?<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_223_27'>\n\t\t\t<div class='gchoice gchoice_223_27_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Yes'  id='choice_223_27_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_223_27_0' id='label_223_27_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_223_27_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='No'  id='choice_223_27_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_223_27_1' id='label_223_27_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_223_28\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_223_28' >If you could change one thing about your skin, what would it be?<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_28' id='input_223_28' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_223_30\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_223_30' >Do you have any special skin challenges or concerns pertaining to your face or body?  If yes, please note<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_223_30' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_223_32\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Have you ever had chemical peels, laser or microdermabrasion?<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_223_32'>\n\t\t\t<div class='gchoice gchoice_223_32_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Yes'  id='choice_223_32_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_223_32_0' id='label_223_32_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_223_32_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='No'  id='choice_223_32_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_223_32_1' id='label_223_32_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_223_33\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >If yes, has it been within the last month?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_223_33'>\n\t\t\t<div class='gchoice gchoice_223_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Yes'  id='choice_223_33_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_223_33_0' id='label_223_33_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_223_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='No'  id='choice_223_33_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_223_33_1' id='label_223_33_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_223_34\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_223_34' >Do you use Retin-A, Renova, Retino, Tretnoin or any Vitamin A derivative products?  If yes, please note<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_34' id='input_223_34' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_223_35\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >If no, have you used any in the past 3 months?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_223_35'>\n\t\t\t<div class='gchoice gchoice_223_35_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Yes'  id='choice_223_35_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_223_35_0' id='label_223_35_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_223_35_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='No'  id='choice_223_35_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_223_35_1' id='label_223_35_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_223_36\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_223_36' >Have you used acne medication?  If yes, when and what drug treatment?<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_36' id='input_223_36' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_223_37\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Have you used any of the following hair removal methods in the past six weeks?  Check all that apply.<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_223_37'><div class='gchoice gchoice_223_37_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.1' type='checkbox'  value='Dermaplane'  id='choice_223_37_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_37_1' id='label_223_37_1'>Dermaplane<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_37_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.2' type='checkbox'  value='Electrolysis'  id='choice_223_37_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_37_2' id='label_223_37_2'>Electrolysis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_37_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.3' type='checkbox'  value='Shaving'  id='choice_223_37_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_37_3' id='label_223_37_3'>Shaving<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_37_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.4' type='checkbox'  value='Laser'  id='choice_223_37_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_37_4' id='label_223_37_4'>Laser<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_37_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.5' type='checkbox'  value='Plucking'  id='choice_223_37_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_37_5' id='label_223_37_5'>Plucking<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_37_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.6' type='checkbox'  value='Tweezing'  id='choice_223_37_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_37_6' id='label_223_37_6'>Tweezing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_37_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.7' type='checkbox'  value='Waxing'  id='choice_223_37_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_37_7' id='label_223_37_7'>Waxing<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_223_38\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Which of the following products do you use on a regular basis?<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_223_38'><div class='gchoice gchoice_223_38_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.1' type='checkbox'  value='Cleanser'  id='choice_223_38_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_38_1' id='label_223_38_1'>Cleanser<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_38_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.2' type='checkbox'  value='Toner'  id='choice_223_38_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_38_2' id='label_223_38_2'>Toner<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_38_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.3' type='checkbox'  value='Day Moisturizer'  id='choice_223_38_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_38_3' id='label_223_38_3'>Day Moisturizer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_38_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.4' type='checkbox'  value='Eye Product'  id='choice_223_38_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_38_4' id='label_223_38_4'>Eye Product<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_38_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.5' type='checkbox'  value='Night Moisturizer'  id='choice_223_38_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_38_5' id='label_223_38_5'>Night Moisturizer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_38_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.6' type='checkbox'  value='Mask'  id='choice_223_38_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_38_6' id='label_223_38_6'>Mask<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_38_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.7' type='checkbox'  value='Scrub'  id='choice_223_38_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_38_7' id='label_223_38_7'>Scrub<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_38_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.8' type='checkbox'  value='Body lotion'  id='choice_223_38_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_38_8' id='label_223_38_8'>Body lotion<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_38_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.9' type='checkbox'  value='Sunscreen'  id='choice_223_38_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_38_9' id='label_223_38_9'>Sunscreen<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_223_38_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.11' type='checkbox'  value='Foundation'  id='choice_223_38_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_223_38_11' id='label_223_38_11'>Foundation<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_223_39\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_223_39' >By digitally signing this intake form, I agree to the St. Vincent&#039;s One Nineteen Spa cancelation policy.  I recognize that if I cancel within 24 hours of my service, it will be marked as a missed appointment.  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