{"id":3956,"date":"2022-06-10T13:00:56","date_gmt":"2022-06-10T17:00:56","guid":{"rendered":"https:\/\/burtonmedicalgroup.sparkexampletwo.com\/?page_id=3956"},"modified":"2023-01-27T12:26:10","modified_gmt":"2023-01-27T17:26:10","slug":"aesthetic-intake-form","status":"publish","type":"page","link":"https:\/\/burtonmedical.a2hosted.com\/newsite\/aesthetic-intake-form\/","title":{"rendered":"Aesthetic Intake Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"3956\" class=\"elementor elementor-3956\">\n\t\t\t\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-691acc6d elementor-section-content-middle elementor-section-stretched elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"691acc6d\" data-element_type=\"section\" data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;,&quot;background_background&quot;:&quot;classic&quot;,&quot;_ha_eqh_enable&quot;:false}\" data-e-bg-lazyload=\"\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-no\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-01174d5 elementor-invisible\" data-id=\"01174d5\" data-element_type=\"column\" data-settings=\"{&quot;animation&quot;:&quot;fadeInUp&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-232c14d elementor-widget-tablet__width-inherit elementor-widget elementor-widget-heading\" data-id=\"232c14d\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.13.2 - 11-05-2023 *\/\n.elementor-heading-title{padding:0;margin:0;line-height:1}.elementor-widget-heading .elementor-heading-title[class*=elementor-size-]>a{color:inherit;font-size:inherit;line-height:inherit}.elementor-widget-heading .elementor-heading-title.elementor-size-small{font-size:15px}.elementor-widget-heading .elementor-heading-title.elementor-size-medium{font-size:19px}.elementor-widget-heading .elementor-heading-title.elementor-size-large{font-size:29px}.elementor-widget-heading .elementor-heading-title.elementor-size-xl{font-size:39px}.elementor-widget-heading .elementor-heading-title.elementor-size-xxl{font-size:59px}<\/style><h1 class=\"elementor-heading-title elementor-size-default\">Aesthetic<br>Intake Form<\/h1>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-4bea462 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"4bea462\" data-element_type=\"section\" id=\"apptschedule\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-1e62809 animated-slow\" data-id=\"1e62809\" data-element_type=\"column\" data-settings=\"{&quot;animation&quot;:&quot;none&quot;,&quot;animation_mobile&quot;:&quot;none&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-995c6e0 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"995c6e0\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-4ed41b3\" data-id=\"4ed41b3\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-3a505e9 elementor-widget elementor-widget-heading\" data-id=\"3a505e9\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Complete the form below<\/h2>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-94b8e45 elementor-widget elementor-widget-heading\" data-id=\"94b8e45\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<span class=\"elementor-heading-title elementor-size-default\">Once the form is submitted, we will contact you as soon as possible.<\/span>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-20ec126 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"20ec126\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-ff7407c\" data-id=\"ff7407c\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-2d1443e elementor-widget-tablet__width-inherit elementor-button-align-start elementor-widget elementor-widget-form\" data-id=\"2d1443e\" data-element_type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor-pro - v3.13.1 - 11-05-2023 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.select-caret-down-wrapper{position:absolute;top:50%;transform:translateY(-50%);inset-inline-end:10px;pointer-events:none;font-size:11px}.elementor-select-wrapper .select-caret-down-wrapper svg{display:unset;width:1em;aspect-ratio:unset;fill:currentColor}.elementor-select-wrapper .select-caret-down-wrapper i{font-size:19px;line-height:2}.elementor-select-wrapper.remove-before:before{content:\"\"!important}<\/style>\t\t<form class=\"elementor-form\" method=\"post\" name=\"Patient Intake Form\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"3956\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"2d1443e\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"Burton Medical Group\" \/>\n\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-name elementor-col-50 elementor-md-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-name\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFirst Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[name]\" id=\"form-field-name\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-help elementor-col-50 elementor-md-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-help\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLast Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[help]\" id=\"form-field-help\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_61ac7c6 elementor-col-30 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_61ac7c6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAddress\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_61ac7c6]\" id=\"form-field-field_61ac7c6\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_fb83a78 elementor-col-30 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_fb83a78\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCity\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_fb83a78]\" id=\"form-field-field_fb83a78\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_546821c elementor-col-20 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_546821c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tState\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_546821c]\" id=\"form-field-field_546821c\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t<option value=\"- Select -\">- Select -<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Alabama\">Alabama<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Alaska\">Alaska<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Arizona\">Arizona<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Arkansas\">Arkansas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"California\">California<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Colorado\">Colorado<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Connecticut\">Connecticut<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Delaware\">Delaware<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Florida\">Florida<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Georgia\">Georgia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Hawaii\">Hawaii<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Idaho\">Idaho<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Illinois\">Illinois<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Indiana\">Indiana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Iowa\">Iowa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kansas\">Kansas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kentucky\">Kentucky<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Louisiana\">Louisiana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Maine\">Maine<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Maryland\">Maryland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Massachusetts\">Massachusetts<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Michigan\">Michigan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Minnesota\">Minnesota<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mississippi\">Mississippi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Missouri\">Missouri<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Montana\">Montana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nebraska\">Nebraska<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nevada\">Nevada<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"New Hampshire\">New Hampshire<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"New Jersey\">New Jersey<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"New Mexico\">New Mexico<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"New York\">New York<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"North Carolina\">North Carolina<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"North Dakota\">North Dakota<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ohio\">Ohio<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Oklahoma\">Oklahoma<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Oregon\">Oregon<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Pennsylvania\">Pennsylvania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Rhode Island\">Rhode Island<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"South Carolina\">South Carolina<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"South Dakota\">South Dakota<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Tennessee\">Tennessee<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Texas\">Texas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Utah\">Utah<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Vermont\">Vermont<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Virginia\">Virginia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Washington\">Washington<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"West Virginia\">West Virginia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Wisconsin\">Wisconsin<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Wyoming\">Wyoming<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_b5a87a3 elementor-col-20 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b5a87a3\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tZip\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_b5a87a3]\" id=\"form-field-field_b5a87a3\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-phone elementor-col-20 elementor-md-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-phone\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[phone]\" id=\"form-field-phone\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t<option value=\"- Select -\">- Select -<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Home\">Home<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Work\">Work<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cell\">Cell<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-number elementor-col-20 elementor-md-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-number\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNumber\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[number]\" id=\"form-field-number\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_1774d19 elementor-col-20 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1774d19\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate of Birth\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_1774d19]\" id=\"form-field-field_1774d19\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" required=\"required\" aria-required=\"true\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_3e75ebb elementor-col-20 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3e75ebb\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSex\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewBox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_3e75ebb]\" id=\"form-field-field_3e75ebb\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t<option value=\"- Select -\">- Select -<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Female\">Female<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Male\">Male<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_34c8b9f elementor-col-80 elementor-md-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_34c8b9f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFamily Doctor\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_34c8b9f]\" id=\"form-field-field_34c8b9f\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_6ea0348 elementor-col-20 elementor-md-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6ea0348\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_6ea0348]\" id=\"form-field-field_6ea0348\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_8f9e5fb elementor-col-80 elementor-md-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8f9e5fb\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPharmacy\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_8f9e5fb]\" id=\"form-field-field_8f9e5fb\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_1575c1e elementor-col-20 elementor-md-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1575c1e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_1575c1e]\" id=\"form-field-field_1575c1e\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_8a7bd02 elementor-col-80 elementor-md-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8a7bd02\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmergency Contact\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_8a7bd02]\" id=\"form-field-field_8a7bd02\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_9acf260 elementor-col-20 elementor-md-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9acf260\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_9acf260]\" id=\"form-field-field_9acf260\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_26f1346 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_26f1346\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWhich body area\/areas or condition would you like treated?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_26f1346]\" id=\"form-field-field_26f1346\" rows=\"5\" required=\"required\" aria-required=\"true\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_deedc4c elementor-col-100\">\n\t\t\t\t\t<strong>Please answer all of the following questions<\/strong>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_c6990ba elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c6990ba\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t1. Do you have ANY current or chronic medical illnesses?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"YES\" id=\"form-field-field_c6990ba-0\" name=\"form_fields[field_c6990ba][]\"> <label for=\"form-field-field_c6990ba-0\">YES<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"NO\" id=\"form-field-field_c6990ba-1\" name=\"form_fields[field_c6990ba][]\"> <label for=\"form-field-field_c6990ba-1\">NO<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_4dd9a68 elementor-col-100\">\n\t\t\t\t\tDisclose any history of heat urticaria, diabetes, autoimmune disorders or any\nimmunosuppression, blood disorders, cancer, bacterial or viral infections,\nmedical conditions that significantly compromise the healing response, skin\nphotosensitivity disorders, or any other condition or illness.\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_bee7880 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_bee7880\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPlease List:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_bee7880]\" id=\"form-field-field_bee7880\" rows=\"4\" required=\"required\" aria-required=\"true\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_2b31848 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2b31848\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t2. Do you have ANY current or chronic skin conditions?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"YES\" id=\"form-field-field_2b31848-0\" name=\"form_fields[field_2b31848][]\"> <label for=\"form-field-field_2b31848-0\">YES<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"NO\" id=\"form-field-field_2b31848-1\" name=\"form_fields[field_2b31848][]\"> <label for=\"form-field-field_2b31848-1\">NO<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_93cf02b elementor-col-100\">\n\t\t\t\t\tAlso disclose any history of vitiligo, eczema, melasma, psoriasis, allergic\ndermatitis, any diseases affecting collagen including Ehlers-Danlos\nsyndrome, scleroderma, skin cancer, or any other skin condition.\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_d41f292 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d41f292\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPlease List:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_d41f292]\" id=\"form-field-field_d41f292\" rows=\"4\" required=\"required\" aria-required=\"true\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_b0977e4 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b0977e4\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t3. Are you currently under a doctor\u2019s care? If so, for what reason?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"YES\" id=\"form-field-field_b0977e4-0\" name=\"form_fields[field_b0977e4][]\"> <label for=\"form-field-field_b0977e4-0\">YES<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"NO\" id=\"form-field-field_b0977e4-1\" name=\"form_fields[field_b0977e4][]\"> <label for=\"form-field-field_b0977e4-1\">NO<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_096eb9b elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_096eb9b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPlease List:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_096eb9b]\" id=\"form-field-field_096eb9b\" rows=\"4\" required=\"required\" aria-required=\"true\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_e35d3fe elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e35d3fe\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t4. Do you take\/use ANY medications (prescriptions and nonprescriptions), vitamins, herbal or natural supplements, on a regular or daily basis?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"YES\" id=\"form-field-field_e35d3fe-0\" name=\"form_fields[field_e35d3fe][]\"> <label for=\"form-field-field_e35d3fe-0\">YES<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"NO\" id=\"form-field-field_e35d3fe-1\" name=\"form_fields[field_e35d3fe][]\"> <label for=\"form-field-field_e35d3fe-1\">NO<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_30bd68c elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_30bd68c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPlease List:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_30bd68c]\" id=\"form-field-field_30bd68c\" rows=\"4\" required=\"required\" aria-required=\"true\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_8e8bbb6 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8e8bbb6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t5. Are there any topical products (both medical and non-medical) that you use on your skin on a regular or daily basis?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"YES\" id=\"form-field-field_8e8bbb6-0\" name=\"form_fields[field_8e8bbb6][]\"> <label for=\"form-field-field_8e8bbb6-0\">YES<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"NO\" id=\"form-field-field_8e8bbb6-1\" name=\"form_fields[field_8e8bbb6][]\"> <label for=\"form-field-field_8e8bbb6-1\">NO<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_0d8415e elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0d8415e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPlease List:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_0d8415e]\" id=\"form-field-field_0d8415e\" rows=\"4\" required=\"required\" aria-required=\"true\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_e2919a8 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e2919a8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t6. Do you take\/use ANY systemic\/oral steroids (e.g., prednisone, dexamethasone)?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"YES\" id=\"form-field-field_e2919a8-0\" name=\"form_fields[field_e2919a8][]\"> <label for=\"form-field-field_e2919a8-0\">YES<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"NO\" id=\"form-field-field_e2919a8-1\" name=\"form_fields[field_e2919a8][]\"> <label for=\"form-field-field_e2919a8-1\">NO<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_1ce7d9a elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1ce7d9a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t7. Do you have ANY allergies to medications, foods, latex or other substances?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"YES\" id=\"form-field-field_1ce7d9a-0\" name=\"form_fields[field_1ce7d9a][]\"> <label for=\"form-field-field_1ce7d9a-0\">YES<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"NO\" id=\"form-field-field_1ce7d9a-1\" name=\"form_fields[field_1ce7d9a][]\"> <label for=\"form-field-field_1ce7d9a-1\">NO<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_2c50855 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2c50855\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPlease List:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_2c50855]\" id=\"form-field-field_2c50855\" rows=\"4\" required=\"required\" aria-required=\"true\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_789d32d elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_789d32d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t8. (For women) are you or could you be pregnant?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"YES\" id=\"form-field-field_789d32d-0\" name=\"form_fields[field_789d32d][]\"> <label for=\"form-field-field_789d32d-0\">YES<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"NO\" id=\"form-field-field_789d32d-1\" name=\"form_fields[field_789d32d][]\"> <label for=\"form-field-field_789d32d-1\">NO<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_b39c8d8 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b39c8d8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t9. (For women) are menstrual periods regular, or have you ever been diagnosed with Polycystic Ovarian Disorder?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"YES\" id=\"form-field-field_b39c8d8-0\" name=\"form_fields[field_b39c8d8][]\"> <label for=\"form-field-field_b39c8d8-0\">YES<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"NO\" id=\"form-field-field_b39c8d8-1\" name=\"form_fields[field_b39c8d8][]\"> <label for=\"form-field-field_b39c8d8-1\">NO<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_318b91f elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_318b91f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t10. Do you have a history of herpes I or II in the area to be treated?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"YES\" id=\"form-field-field_318b91f-0\" name=\"form_fields[field_318b91f][]\"> <label for=\"form-field-field_318b91f-0\">YES<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"NO\" id=\"form-field-field_318b91f-1\" name=\"form_fields[field_318b91f][]\"> <label for=\"form-field-field_318b91f-1\">NO<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_4efbeb9 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4efbeb9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t11. Do you have a history of keloid scarring or hypertrophic scar formation?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"YES\" id=\"form-field-field_4efbeb9-0\" name=\"form_fields[field_4efbeb9][]\"> <label for=\"form-field-field_4efbeb9-0\">YES<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"NO\" id=\"form-field-field_4efbeb9-1\" name=\"form_fields[field_4efbeb9][]\"> <label for=\"form-field-field_4efbeb9-1\">NO<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_3f88348 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3f88348\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t12. Do you have a history of light induced seizures?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"YES\" id=\"form-field-field_3f88348-0\" name=\"form_fields[field_3f88348][]\"> <label for=\"form-field-field_3f88348-0\">YES<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"NO\" id=\"form-field-field_3f88348-1\" name=\"form_fields[field_3f88348][]\"> <label for=\"form-field-field_3f88348-1\">NO<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_f92f8d1 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f92f8d1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t13. Do you have any open sores or lesions?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"YES\" id=\"form-field-field_f92f8d1-0\" name=\"form_fields[field_f92f8d1][]\"> <label for=\"form-field-field_f92f8d1-0\">YES<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"NO\" id=\"form-field-field_f92f8d1-1\" name=\"form_fields[field_f92f8d1][]\"> <label for=\"form-field-field_f92f8d1-1\">NO<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_081e8f9 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_081e8f9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t14. Do you have any history of radiation therapy in the area to be treated?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"YES\" id=\"form-field-field_081e8f9-0\" name=\"form_fields[field_081e8f9][]\"> <label for=\"form-field-field_081e8f9-0\">YES<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"NO\" id=\"form-field-field_081e8f9-1\" name=\"form_fields[field_081e8f9][]\"> <label for=\"form-field-field_081e8f9-1\">NO<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_02ca91e elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_02ca91e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t15. In the last six (6) months, have you used any of the following: anticoagulants or blood-thinning medications; photosensitizing medications; or anti-inflammatory or blood thinning medications?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"YES\" id=\"form-field-field_02ca91e-0\" name=\"form_fields[field_02ca91e][]\"> <label for=\"form-field-field_02ca91e-0\">YES<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"NO\" id=\"form-field-field_02ca91e-1\" name=\"form_fields[field_02ca91e][]\"> <label for=\"form-field-field_02ca91e-1\">NO<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_d371f3b elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d371f3b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPlease List product name and date last used:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_d371f3b]\" id=\"form-field-field_d371f3b\" rows=\"4\" required=\"required\" aria-required=\"true\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_a122d8e elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a122d8e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t16. In the last three (3) months, have you used any of the following products: glycolic acid or otheralphahydroxy or betahydroxyacid acid products; exfoliating or resurfacing products or treatments?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"YES\" id=\"form-field-field_a122d8e-0\" name=\"form_fields[field_a122d8e][]\"> <label for=\"form-field-field_a122d8e-0\">YES<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"NO\" id=\"form-field-field_a122d8e-1\" name=\"form_fields[field_a122d8e][]\"> <label for=\"form-field-field_a122d8e-1\">NO<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_dd72275 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_dd72275\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPlease List product name and date last used:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_dd72275]\" id=\"form-field-field_dd72275\" rows=\"4\" required=\"required\" aria-required=\"true\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_78b64a0 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_78b64a0\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t17. Do you have or have you ever had any permanent make-up, tattoos, implants, or fillers,including, but not limited to, collagen, autologous fat, Restylane\u00ae, etc.?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"YES\" id=\"form-field-field_78b64a0-0\" name=\"form_fields[field_78b64a0][]\"> <label for=\"form-field-field_78b64a0-0\">YES<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"NO\" id=\"form-field-field_78b64a0-1\" name=\"form_fields[field_78b64a0][]\"> <label for=\"form-field-field_78b64a0-1\">NO<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_f51ca2a elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f51ca2a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf yes, please list locations on or in the body and dates:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_f51ca2a]\" id=\"form-field-field_f51ca2a\" rows=\"4\" required=\"required\" aria-required=\"true\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_f27af6f elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f27af6f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t18. Do you have or have you ever had any Botulinums, such as Botox\u00ae or Dysport\u00ae?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"YES\" id=\"form-field-field_f27af6f-0\" name=\"form_fields[field_f27af6f][]\"> <label for=\"form-field-field_f27af6f-0\">YES<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"NO\" id=\"form-field-field_f27af6f-1\" name=\"form_fields[field_f27af6f][]\"> <label for=\"form-field-field_f27af6f-1\">NO<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_7e0248c elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7e0248c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf yes, please list locations on or in the body and dates:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_7e0248c]\" id=\"form-field-field_7e0248c\" rows=\"4\" required=\"required\" aria-required=\"true\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_e4d728d elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e4d728d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t19. Have you taken Accutane\u00ae (or products containing isotretinoin) in the last 12 months?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"YES\" id=\"form-field-field_e4d728d-0\" name=\"form_fields[field_e4d728d][]\"> <label for=\"form-field-field_e4d728d-0\">YES<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"NO\" id=\"form-field-field_e4d728d-1\" name=\"form_fields[field_e4d728d][]\"> <label for=\"form-field-field_e4d728d-1\">NO<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_d711f29 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d711f29\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t20. Have you taken Tretinoin (like Retin-A\uf0d2, Renova\uf0d2) in the last 6 months?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"YES\" id=\"form-field-field_d711f29-0\" name=\"form_fields[field_d711f29][]\"> <label for=\"form-field-field_d711f29-0\">YES<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"NO\" id=\"form-field-field_d711f29-1\" name=\"form_fields[field_d711f29][]\"> <label for=\"form-field-field_d711f29-1\">NO<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_d6f355c elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d6f355c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t21. Have you had any unprotected sun exposure, used tanning creams (including sunless tanning lotions) or tanning beds or lamps in the last 4-6 weeks?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"YES\" id=\"form-field-field_d6f355c-0\" name=\"form_fields[field_d6f355c][]\"> <label for=\"form-field-field_d6f355c-0\">YES<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"NO\" id=\"form-field-field_d6f355c-1\" name=\"form_fields[field_d6f355c][]\"> <label for=\"form-field-field_d6f355c-1\">NO<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_f0b4a1e elementor-col-30 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f0b4a1e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDigital Signature\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_f0b4a1e]\" id=\"form-field-field_f0b4a1e\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"(FIRST &amp; LAST NAME)\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_500f2ee elementor-col-20 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_500f2ee\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_500f2ee]\" id=\"form-field-field_500f2ee\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" required=\"required\" aria-required=\"true\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\" min=\"2022-06-10\" max=\"2030-12-31\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button type=\"submit\" class=\"elementor-button elementor-size-md\">\n\t\t\t\t\t\t<span >\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\" elementor-button-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Submit Form<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>AestheticIntake Form Complete the form below Once the form is submitted, we will contact you as soon as possible.<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v20.7 - 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