{"id":20305,"date":"2023-08-08T17:56:27","date_gmt":"2023-08-08T17:56:27","guid":{"rendered":"https:\/\/byebyeink.nyc\/?page_id=20305"},"modified":"2023-09-05T15:45:16","modified_gmt":"2023-09-05T15:45:16","slug":"virtual-consultation-form","status":"publish","type":"page","link":"https:\/\/byebyeink.nyc\/virtual-consultation-form\/","title":{"rendered":"Virtual Consultation\u00a0Form"},"content":{"rendered":"    <script type=\"text\/javascript\">\n        jQuery(document).on('gform_post_render', function(){\n            \/* apply only to a input with a class of gf_readonly *\/\n            jQuery(\".gf_readonly input\").attr(\"readonly\",\"readonly\");\n        });\n    <\/script>\n    <script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),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),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_unknown gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_2' style='display:none'><div id='gf_2' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/wp-json\/wp\/v2\/pages\/20305#gf_2' data-formid='2' >\n        <div id='gf_progressbar_wrapper_2' 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'>5<\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_20' style='width:20%;'><span>20%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_2_1' class='gform_page ' data-js='page-field-id-129' >\n                                    <div class='gform_page_fields'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_2_3\"  class=\"gfield gfield--type-html gfield--width-full exclude gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_3\"><h1><center>Client Medical History<\/center><\/h1><\/div><div id=\"field_2_114\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_114\"><h3>PERSONAL HISTORY <\/h3><\/div><div id=\"field_2_1\"  class=\"gfield gfield--type-text gfield--width-three-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_1\"><label class='gfield_label gform-field-label' for='input_2_1' >Client Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_2_1' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_125\"  class=\"gfield gfield--type-text gfield--width-quarter gf_readonly field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_125\"><label class='gfield_label gform-field-label' for='input_2_125' >Date<\/label><div class='ginput_container ginput_container_text'><input name='input_125' id='input_2_125' type='text' value='03\/04\/2024' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_7\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_7\"><label class='gfield_label gform-field-label' for='input_2_7' >Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_7' id='input_2_7' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_7_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_2_7_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_7' class='gform_hidden' value='https:\/\/byebyeink.nyc\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_2_8\"  class=\"gfield gfield--type-number gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_8\"><label class='gfield_label gform-field-label' for='input_2_8' >Age<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_8' id='input_2_8' type='text'    value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_2_9\"  class=\"gfield gfield--type-text gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_9\"><label class='gfield_label gform-field-label' for='input_2_9' >Occupation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_2_9' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_10\"  class=\"gfield gfield--type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_10\"><label class='gfield_label gform-field-label' for='input_2_10' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_2_10' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_11\"  class=\"gfield gfield--type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_11\"><label class='gfield_label gform-field-label' for='input_2_11' >City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_2_11' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_13\"  class=\"gfield gfield--type-select gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_13\"><label class='gfield_label gform-field-label' for='input_2_13' >State<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_13' id='input_2_13' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><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><\/div><\/div><div id=\"field_2_14\"  class=\"gfield gfield--type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_14\"><label class='gfield_label gform-field-label' for='input_2_14' >Zip Code<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_2_14' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_16\"  class=\"gfield gfield--type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_16\"><label class='gfield_label gform-field-label' for='input_2_16' >Cell Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_16' id='input_2_16' type='text' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_17\"  class=\"gfield gfield--type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_17\"><label class='gfield_label gform-field-label' for='input_2_17' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_17' id='input_2_17' type='text' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_2_19\"  class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_19\"><label class='gfield_label gform-field-label' for='input_2_19' >Emergency Contact Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_2_19' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_20\"  class=\"gfield gfield--type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_20\"><label class='gfield_label gform-field-label' for='input_2_20' >Emergency Contact Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_20' id='input_2_20' type='text' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_21\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_21\"><label class='gfield_label gform-field-label' for='input_2_21' >How were you referred to us?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_2_21' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_22\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gf_list_3col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_22\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Which of the following best describes your skin type? (Please select one or more if unsure)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_22'><div class='gchoice gchoice_2_22_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.1' type='checkbox'  value='Always burns, never tans'  id='choice_2_22_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_1' id='label_2_22_1' class='gform-field-label gform-field-label--type-inline'>Always burns, never tans<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.2' type='checkbox'  value='Always burns, sometimes tans'  id='choice_2_22_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_2' id='label_2_22_2' class='gform-field-label gform-field-label--type-inline'>Always burns, sometimes tans<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.3' type='checkbox'  value='Sometimes burns, always tans'  id='choice_2_22_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_3' id='label_2_22_3' class='gform-field-label gform-field-label--type-inline'>Sometimes burns, always tans<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.4' type='checkbox'  value='Rarely burns, always tans'  id='choice_2_22_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_4' id='label_2_22_4' class='gform-field-label gform-field-label--type-inline'>Rarely burns, always tans<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.5' type='checkbox'  value='Brown, moderately pigmented skin'  id='choice_2_22_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_5' id='label_2_22_5' class='gform-field-label gform-field-label--type-inline'>Brown, moderately pigmented skin<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.6' type='checkbox'  value='Deeply pigmented, never burns'  id='choice_2_22_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_6' id='label_2_22_6' class='gform-field-label gform-field-label--type-inline'>Deeply pigmented, never burns<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_5\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_5\"><h3>MEDICAL HISTORY<\/h3><\/div><fieldset id=\"field_2_99\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_4col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_99\"><legend class='gfield_label gform-field-label'  >Are you currently under the care of a physician?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_99'>\n\t\t\t<div class='gchoice gchoice_2_99_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_99' type='radio' value='Yes'  id='choice_2_99_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_99_0' id='label_2_99_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_2_99_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_99' type='radio' value='No'  id='choice_2_99_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_99_1' id='label_2_99_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_25\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_25\"><label class='gfield_label gform-field-label' for='input_2_25' >If yes, for what:<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_2_25' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_100\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_4col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_100\"><legend class='gfield_label gform-field-label'  >Are you currently under the care of a dermatologist?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_100'>\n\t\t\t<div class='gchoice gchoice_2_100_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_100' type='radio' value='Yes'  id='choice_2_100_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_100_0' id='label_2_100_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_2_100_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_100' type='radio' value='No'  id='choice_2_100_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_100_1' id='label_2_100_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_27\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_27\"><label class='gfield_label gform-field-label' for='input_2_27' >If yes, for what:<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_2_27' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_101\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_4col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_101\"><legend class='gfield_label gform-field-label'  >Do you have a history of erythema or Eczema which is a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat or infrared irritation?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_101'>\n\t\t\t<div class='gchoice gchoice_2_101_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='Yes'  id='choice_2_101_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_101_0' id='label_2_101_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_2_101_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='No'  id='choice_2_101_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_101_1' id='label_2_101_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_29\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gf_list_3col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_29\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Do you have any of the following medical conditions?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_29'><div class='gchoice gchoice_2_29_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.1' type='checkbox'  value='Cancer'  id='choice_2_29_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_29_1' id='label_2_29_1' class='gform-field-label gform-field-label--type-inline'>Cancer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_29_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.2' type='checkbox'  value='Diabetes'  id='choice_2_29_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_29_2' id='label_2_29_2' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_29_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.3' type='checkbox'  value='High blood pressure'  id='choice_2_29_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_29_3' id='label_2_29_3' class='gform-field-label gform-field-label--type-inline'>High blood pressure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_29_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.4' type='checkbox'  value='Herpes'  id='choice_2_29_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_29_4' id='label_2_29_4' class='gform-field-label gform-field-label--type-inline'>Herpes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_29_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.5' type='checkbox'  value='Arthritis'  id='choice_2_29_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_29_5' id='label_2_29_5' class='gform-field-label gform-field-label--type-inline'>Arthritis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_29_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.6' type='checkbox'  value='Frequent cold sores'  id='choice_2_29_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_29_6' id='label_2_29_6' class='gform-field-label gform-field-label--type-inline'>Frequent cold sores<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_29_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.7' type='checkbox'  value='HIV\/AIDS'  id='choice_2_29_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_29_7' id='label_2_29_7' class='gform-field-label gform-field-label--type-inline'>HIV\/AIDS<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_29_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.8' type='checkbox'  value='Keloid scarring'  id='choice_2_29_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_29_8' id='label_2_29_8' class='gform-field-label gform-field-label--type-inline'>Keloid scarring<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_29_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.9' type='checkbox'  value='Skin disease\/Skin lesions'  id='choice_2_29_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_29_9' id='label_2_29_9' class='gform-field-label gform-field-label--type-inline'>Skin disease\/Skin lesions<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_29_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.11' type='checkbox'  value='Seizure disorder'  id='choice_2_29_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_29_11' id='label_2_29_11' class='gform-field-label gform-field-label--type-inline'>Seizure disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_29_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.12' type='checkbox'  value='Hepatitis'  id='choice_2_29_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_29_12' id='label_2_29_12' class='gform-field-label gform-field-label--type-inline'>Hepatitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_29_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.13' type='checkbox'  value='Blood clotting abnormalities'  id='choice_2_29_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_29_13' id='label_2_29_13' class='gform-field-label gform-field-label--type-inline'>Blood clotting abnormalities<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_29_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.14' type='checkbox'  value='Any active infection'  id='choice_2_29_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_29_14' id='label_2_29_14' class='gform-field-label gform-field-label--type-inline'>Any active infection<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_34\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_34\"><label class='gfield_label gform-field-label' for='input_2_34' >Do you have any other health problems or medical conditions?<\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_2_34' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_2_4' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"2\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"2\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_2' class='gform_page' data-js='page-field-id-4' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_2' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_2_35\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_35\"><h3>MEDICATIONS<\/h3><\/div><fieldset id=\"field_2_121\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_4col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_121\"><legend class='gfield_label gform-field-label'  >Are you on any mood altering or anxiety suppression medication?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_121'>\n\t\t\t<div class='gchoice gchoice_2_121_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='Yes'  id='choice_2_121_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_121_0' id='label_2_121_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_2_121_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='No'  id='choice_2_121_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_121_1' id='label_2_121_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_122\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_122\"><label class='gfield_label gform-field-label' for='input_2_122' >If yes, which ones<\/label><div class='ginput_container ginput_container_text'><input name='input_122' id='input_2_122' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_102\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_4col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_102\"><legend class='gfield_label gform-field-label'  >Have you ever used any prescribed acne medication (Accutane, Epiduo, etc.)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_102'>\n\t\t\t<div class='gchoice gchoice_2_102_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_102' type='radio' value='Yes'  id='choice_2_102_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_102_0' id='label_2_102_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_2_102_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_102' type='radio' value='No'  id='choice_2_102_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_102_1' id='label_2_102_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_39\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_39\"><label class='gfield_label gform-field-label' for='input_2_39' >If yes, when did you last use it?<\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_2_39' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_103\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_4col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_103\"><legend class='gfield_label gform-field-label'  >What topical medications or creams are you currently using?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_103'>\n\t\t\t<div class='gchoice gchoice_2_103_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='RetinA'  id='choice_2_103_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_103_0' id='label_2_103_0' class='gform-field-label gform-field-label--type-inline'>RetinA<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_103_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='gf_other_choice'  id='choice_2_103_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_103_1' id='label_2_103_1' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_2_103_other' class='gchoice_other_control' name='input_103_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_44\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_44\"><h3>HISTORY<\/h3><\/div><fieldset id=\"field_2_104\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_4col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_104\"><legend class='gfield_label gform-field-label'  >Have you ever had any type of laser treatments in the past?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_104'>\n\t\t\t<div class='gchoice gchoice_2_104_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_104' type='radio' value='Yes'  id='choice_2_104_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_104_0' id='label_2_104_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_2_104_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_104' type='radio' value='No'  id='choice_2_104_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_104_1' id='label_2_104_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_46\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_46\"><label class='gfield_label gform-field-label' for='input_2_46' >If yes, Please list<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_2_46' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_105\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_3col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_105\"><legend class='gfield_label gform-field-label'  >Do you smoke cigarettes or tobacco regularly?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_105'>\n\t\t\t<div class='gchoice gchoice_2_105_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_105' type='radio' value='Yes'  id='choice_2_105_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_105_0' id='label_2_105_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_2_105_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_105' type='radio' value='No'  id='choice_2_105_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_105_1' id='label_2_105_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_106\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_3col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_106\"><legend class='gfield_label gform-field-label'  >Have you had any recent tanning or sun exposure that changed the color of your skin?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_106'>\n\t\t\t<div class='gchoice gchoice_2_106_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_106' type='radio' value='Yes'  id='choice_2_106_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_106_0' id='label_2_106_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_2_106_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_106' type='radio' value='No'  id='choice_2_106_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_106_1' id='label_2_106_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_107\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_3col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_107\"><legend class='gfield_label gform-field-label'  >Have you recently used any self-tanning lotions or treatments?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_107'>\n\t\t\t<div class='gchoice gchoice_2_107_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_107' type='radio' value='Yes'  id='choice_2_107_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_107_0' id='label_2_107_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_2_107_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_107' type='radio' value='No'  id='choice_2_107_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_107_1' id='label_2_107_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_108\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_3col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_108\"><legend class='gfield_label gform-field-label'  >Do you form thick or raised scars from cuts or burns?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_108'>\n\t\t\t<div class='gchoice gchoice_2_108_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_108' type='radio' value='Yes'  id='choice_2_108_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_108_0' id='label_2_108_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_2_108_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_108' type='radio' value='No'  id='choice_2_108_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_108_1' id='label_2_108_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_109\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_3col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_109\"><legend class='gfield_label gform-field-label'  >Do you have hyper pigmentation (darkening of the skin) or hypo pigmentation (lightening of the skin or marks after physical trauma)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_109'>\n\t\t\t<div class='gchoice gchoice_2_109_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_109' type='radio' value='Yes'  id='choice_2_109_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_109_0' id='label_2_109_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_2_109_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_109' type='radio' value='No'  id='choice_2_109_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_109_1' id='label_2_109_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_54\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_54\"><label class='gfield_label gform-field-label' for='input_2_54' >If yes, please describe:<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_2_54' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_55\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_55\"><h3>WOMAN CLIENTS ONLY<\/h3><\/div><fieldset id=\"field_2_111\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_3col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_111\"><legend class='gfield_label gform-field-label'  >Are you pregnant or trying to become pregnant?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_111'>\n\t\t\t<div class='gchoice gchoice_2_111_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_111' type='radio' value='Yes'  id='choice_2_111_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_111_0' id='label_2_111_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_2_111_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_111' type='radio' value='No'  id='choice_2_111_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_111_1' id='label_2_111_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_112\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_3col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_112\"><legend class='gfield_label gform-field-label'  >Are you breastfeeding?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_112'>\n\t\t\t<div class='gchoice gchoice_2_112_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_112' type='radio' value='Yes'  id='choice_2_112_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_112_0' id='label_2_112_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_2_112_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_112' type='radio' value='No'  id='choice_2_112_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_112_1' id='label_2_112_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_58\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_58\">I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the laser technician of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.<\/div><div id=\"field_2_124\"  class=\"gfield gfield--type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_124\">Signature<\/div><div id=\"field_2_126\"  class=\"gfield gfield--type-text gfield--width-half gf_readonly field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_126\"><label class='gfield_label gform-field-label' for='input_2_126' >Date<\/label><div class='ginput_container ginput_container_text'><input name='input_126' id='input_2_126' type='text' value='03\/04\/2024' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_61' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"1\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"1\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_2_61' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"3\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"3\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_3' class='gform_page' data-js='page-field-id-61' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_3' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_2_65\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_65\"><h1>INFORMED CONSENT FOR LASER TATTOO REMOVAL<\/h1><\/div><div id=\"field_2_70\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_70\"><label class='gfield_label gform-field-label' for='input_2_70' >I<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_2_70' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_68\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_68\">consent to and authorize Bye Bye Ink to perform multiple treatments, laser procedures and related services on me. The procedure planned uses laser technology for the removal of tattoos. <\/div><div id=\"field_2_67\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_67\"><p>As a patient, you have the right to be informed about your treatment so that you may make the decision whether to proceed for laser tattoo removal or decline after knowing the risks involved. This disclosure is to help to inform you prior to your consent for treatment about the risks, side effects and possible complications related to laser tattoo removal: <\/p>\n<p>The following problems may occur with the tattoo removal system.<\/p>\n<ol>\n    <li><b>The possible risks of the procedure include but are not limited to:<\/b> pain, purpura, swelling, redness, bruising, blistering, crusting\/scab formation, ingrown hairs, infection, and unforeseen complications which can last up to many months, years or permanently<\/li>\n    <li><b>There is a less than .05% risk of scarring.<\/b> Scarring happens, but is uncommon. Scarring can be permanent.<\/li>\n    <li><b>Short-term effects may include reddening, mild burning, temporary bruising or blistering.<\/b> A brownish\/red darkening of the skin (known as hyper-pigmentation) or lightening of the skin (known as hypo-pigmentation) may occur at times up to 3-6 months, years or permanently following treatment. Loss of freckles or pigmented lesions can occur.<\/li>\n    <li><b>Textual changes<\/b> in the skin can occur and can be permanent.<\/li>\n    <li><b>Infection: <\/b> Although infection following treatment is unusual, bacterial, fungal and viral infections can occur. Herpes simplex virus infections around the mouth can occur following a treatment. This applies to both individuals with a past history of herpes simplex virus infections and individuals with no known history of herpes simplex virus infections in the mouth area. Should any type of skin infection occur, additional treatments or medical antibiotics may be necessary.<\/li>\n    <li><b>Bleeding:<\/b> Pinpoint bleeding is rare but can occur following treatment procedures. Should bleeding occur, additional treatment may be necessary.<\/li>\n    <li><b>Allergic Reactions:<\/b> Upon dissemination, the pigments can induce a severe allergic reaction that can occur with each successive treatment. Noted in some patients are superficial erosions, bruising, blistering, redness and swelling which can last up to many months, years or permanently.<\/li>\n    <li>I understand that exposure of my eyes to light could harm my vision. <b>I must keep the eye protection goggles on at all times.<\/b><\/li>\n    <li><b>Compliance with the aftercare guidelines<\/b> is crucial for healing, prevention of scarring, and hyper-pigmentation.<\/li>\n<\/ol><\/div><div id=\"field_2_75\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_75\"><p>Occasionally, unforeseen mechanical problems may occur and your appointment will need to be rescheduled. We will make every effort to notify you prior to your arrival to the office. Please be understanding if we cause you any inconvenience.<\/p>\n<p><u><b>ACKNOWLEDGMENT<\/b><\/u><br>\nMy questions regarding the procedure have been answered satisfactorily. I understand the procedure and I accept the risks. I hereby release Jacqueline Gibbs and Bye Bye Ink from all liabilities associated with the above indicated procedure. <\/p>\n<p><u><b>DISCLAIMER<\/b><\/u><br>\nAll sales are final and non-refundable. Tattoo Removal Sessions are valid for one year from the original purchase date. Clients are limited to ONE sale and\/or discount per tattoo.<\/p><\/div><div id=\"field_2_119\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_119\"><label class='gfield_label gform-field-label' for='input_2_119' >Client\/Guardian Name<\/label><div class='ginput_container ginput_container_text'><input name='input_119' id='input_2_119' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_120\"  class=\"gfield gfield--type-text gfield--width-half gf_readonly field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_120\"><label class='gfield_label gform-field-label' for='input_2_120' >Laser Technician Name<\/label><div class='ginput_container ginput_container_text'><input name='input_120' id='input_2_120' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_127\"  class=\"gfield gfield--type-text gfield--width-half gf_readonly field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_127\"><label class='gfield_label gform-field-label' for='input_2_127' >Date<\/label><div class='ginput_container ginput_container_text'><input name='input_127' id='input_2_127' type='text' value='03\/04\/2024' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_128\"  class=\"gfield gfield--type-text gfield--width-half gf_readonly field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_128\"><label class='gfield_label gform-field-label' for='input_2_128' >Date<\/label><div class='ginput_container ginput_container_text'><input name='input_128' id='input_2_128' type='text' value='03\/04\/2024' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_63' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"2\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"2\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_2_63' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"4\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"4\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_4' class='gform_page' data-js='page-field-id-63' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_4' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_2_72\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_72\"><h1>Tattoo(s) Description<\/h1><\/div><div id=\"field_2_80\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_80\">Please provide all the pertinent details about the tattoo(s) you want to remove and\/or lighten:<\/div><div id=\"field_2_81\"  class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_81\"><label class='gfield_label gform-field-label' for='input_2_81' >Age of Tattoo?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_81' id='input_2_81' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_82\"  class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_82\"><label class='gfield_label gform-field-label' for='input_2_82' >Location of Tattoo?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_82' id='input_2_82' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_83\"  class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_83\"><label class='gfield_label gform-field-label' for='input_2_83' >Approx Size?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_83' id='input_2_83' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_84\"  class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_84\"><label class='gfield_label gform-field-label' for='input_2_84' >Color(s)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_84' id='input_2_84' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_116\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_3col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_116\"><legend class='gfield_label gform-field-label'  >Coverup<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_116'>\n\t\t\t<div class='gchoice gchoice_2_116_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_116' type='radio' value='Yes'  id='choice_2_116_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_116_0' id='label_2_116_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_2_116_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_116' type='radio' value='No'  id='choice_2_116_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_116_1' id='label_2_116_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_86\"  class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_86\"><label class='gfield_label gform-field-label' for='input_2_86' >Was your tattoo done by a professional or amateur?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_86' id='input_2_86' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_117\"  class=\"gfield gfield--type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_117\"><label class='gfield_label gform-field-label' for='gform_browse_button_2_117' >Please upload a picture of your tattoo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_2_117' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_2_117&quot;,&quot;container&quot;:&quot;gform_multifile_upload_2_117&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_2_117&quot;,&quot;filelist&quot;:&quot;gform_preview_2_117&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/byebyeink.nyc\\\/?gf_page=3e30db9b7ca0de8&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/byebyeink.nyc\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/byebyeink.nyc\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpeg,jpg,png&quot;}],&quot;max_file_size&quot;:&quot;52428800b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:2,&quot;field_id&quot;:117},&quot;gf_vars&quot;:{&quot;max_files&quot;:&quot;4&quot;,&quot;message_id&quot;:&quot;gform_multifile_messages_2_117&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_2_117' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_2_117' class='button gform_button_select_files' aria-describedby=\"gfield_upload_rules_2_117\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_2_117'>Accepted file types: jpeg, jpg, png, Max. file size: 50 MB, Max. files: 4.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_2_117'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_2_117' class='ginput_preview_list'><\/div><\/div><div id=\"field_2_87\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_87\"><h1>Microblading\/Eyebrow Tattoos ONLY<\/h1><\/div><div id=\"field_2_88\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_88\">Please provide all the pertinent details about the tattoo(s) you want to remove and\/or lighten:<\/div><div id=\"field_2_89\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_89\"><label class='gfield_label gform-field-label' for='input_2_89' >Age of Microblading\/Tattoo:<\/label><div class='ginput_container ginput_container_text'><input name='input_89' id='input_2_89' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_90\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_90\"><label class='gfield_label gform-field-label' for='input_2_90' >How many times were they done including touchups?<\/label><div class='ginput_container ginput_container_text'><input name='input_90' id='input_2_90' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_91\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_91\"><label class='gfield_label gform-field-label' for='input_2_91' >When was the last time you had them done?<\/label><div class='ginput_container ginput_container_text'><input name='input_91' id='input_2_91' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_92\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_92\"><label class='gfield_label gform-field-label' for='input_2_92' >Do you have shading\/ombre?<\/label><div class='ginput_container ginput_container_text'><input name='input_92' id='input_2_92' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_93\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_93\"><label class='gfield_label gform-field-label' for='input_2_93' >What color is your eyebrow pigment currently?<\/label><div class='ginput_container ginput_container_text'><input name='input_93' id='input_2_93' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_94\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_94\"><label class='gfield_label gform-field-label' for='input_2_94' >Have you had saline or laser removal previously?<\/label><div class='ginput_container ginput_container_text'><input name='input_94' id='input_2_94' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_95\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_95\"><label class='gfield_label gform-field-label' for='input_2_95' >If yes, how many times and how long ago?<\/label><div class='ginput_container ginput_container_text'><input name='input_95' id='input_2_95' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class=\"spacer gfield\" style=\"grid-column: span 3;\"><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_64' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"3\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"3\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_2_64' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"5\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"5\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_5' class='gform_page' data-js='page-field-id-64' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_5' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_2_73\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_73\"><p>We strive to render excellent customer service and treatment(s) to all our clients. In an attempt to be consistent with this, please understand that our schedule is appointment based. When an appointment is scheduled, that time has been set aside for you and when it is missed, that time cannot be used to treat another patients.<\/p>\n\n<p><b><u>24-Hour Cancellation Policy:<\/u><\/b><br>\nPlease be advised all clients are subject to our 24-Hour cancellation policy. If you are unable to keep your appointment, our office requires a 24-hour courtesy notification before the reserved appointment date and time. If your appointment was made within 24 hours, you have a grace period of four hours to cancel and\/or reschedule without penalty.<\/p>\n\n<p>We ask that all new and current clients supply a credit card and Photo ID to have on file. In the event that we do not receive the required 24-Hour notice for adjustments and cancellations, please be advised that you will be responsible for the following terms and conditions:<\/p>\n\n<p><b style=\"color: #ff0000;\">Please notify our office via Phone\/Voicemail (347) 396-5234 or by E-Mail: info@wordpress-1083618-3869124.cloudwaysapps.com<\/b><\/p>\n<p><b style=\"color: #ff0000;\">A missed call without leaving a voicemail and\/or not confirming to the Mindbody software\u2019s automated email and text appointment reminder DOES NOT cancel your appointment.<\/b><\/p>\n<p><b style=\"color: #ff0000;\">Notification given at least 24 hours prior to your appointment will receive no charges.<\/b><\/p>\n<p><b style=\"color: #ff0000;\">Notification given less than 24 hours prior to appointment time will result in 50% of the scheduled service price and\/or lose a pre-paid package session.<\/b><\/p>\n<p><b style=\"color: #ff0000;\">Failure to show up for your appointment without notification will result in a 100% charge of the reserved service price.<\/b><\/p>\n<p><b style=\"color: #ff0000;\">If the card declines, a hold will be put on your profile in our system. Please note ALL FEES must be paid in order to book a new appointment.<\/b><\/p>\n\n<p><b><u>Late Arrivals:<\/u><\/b><br>\nWe make every effort to be on time for all our appointments. Unfortunately, when even one patient arrives late, it can throw off the entire schedule for that session. <\/p>\n\n<p><b style=\"color: #ff0000;\"> Clients arriving more than 15 minutes after their appointment time will be liable for a $15 late fee<\/b><\/p>\n\n<p>Thank you for your understanding. We appreciate your business and time and trust you respect mine.<\/p>\n<\/div><div id=\"field_2_96\"  class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_96\"><label class='gfield_label gform-field-label' for='input_2_96' >Print Name<\/label><div class='ginput_container ginput_container_text'><input name='input_96' id='input_2_96' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_123\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_123\">Signature<\/div><div id=\"field_2_129\"  class=\"gfield gfield--type-text gfield--width-third gf_readonly field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_129\"><label class='gfield_label gform-field-label' for='input_2_129' >Date<\/label><div class='ginput_container ginput_container_text'><input name='input_129' id='input_2_129' type='text' value='03\/04\/2024' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><\/div><\/div>\n        <div class='gform_page_footer top_label'><input type='submit' id='gform_previous_button_2' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='if(window[\"gf_submitting_2\"]){return false;}  window[\"gf_submitting_2\"]=true;  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_2\"]){return false;} window[\"gf_submitting_2\"]=true;  jQuery(\"#gform_2\").trigger(\"submit\",[true]); }' \/> <input type='submit' id='gform_submit_button_2' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_2\"]){return false;}  window[\"gf_submitting_2\"]=true;  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_2\"]){return false;} window[\"gf_submitting_2\"]=true;  jQuery(\"#gform_2\").trigger(\"submit\",[true]); }' \/> \n            <input type='hidden' class='gform_hidden' name='is_submit_2' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='2' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_2' 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