{"id":1183,"date":"2021-02-17T02:40:04","date_gmt":"2021-02-17T07:40:04","guid":{"rendered":"https:\/\/www.lenoxesthetics.com\/?page_id=1183"},"modified":"2022-02-16T11:29:35","modified_gmt":"2022-02-16T16:29:35","slug":"laser-treatment-consent-form","status":"publish","type":"page","link":"https:\/\/www.lenoxesthetics.com\/?page_id=1183","title":{"rendered":"Laser Treatment Consent Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1183\" class=\"elementor elementor-1183\">\n\t\t\t\t\t\t<div class=\"elementor-inner\">\n\t\t\t\t<div class=\"elementor-section-wrap\">\n\t\t\t\t\t\t\t\t\t<section data-particle_enable=\"false\" data-particle-mobile-disabled=\"false\" class=\"elementor-section elementor-top-section elementor-element elementor-element-6ef56e59 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"6ef56e59\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t\t\t<div class=\"elementor-row\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-5d43c698\" data-id=\"5d43c698\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-column-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-baf34e1 elementor-widget elementor-widget-shortcode\" data-id=\"baf34e1\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-shortcode\">\n                <div class='gf_browser_gecko gform_wrapper' id='gform_wrapper_5' style='display:none'><a id='gf_5' class='gform_anchor' ><\/a><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_5' id='gform_5'  action='\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F1183#gf_5'>\n        <div id='gf_progressbar_wrapper_5' class='gf_progressbar_wrapper'>\n            <h3 class='gf_progressbar_title'>Step 1 of 3\n        <\/h3>\n            <div class='gf_progressbar'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_33' style='width:33%;'><span>33%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform_body'><div id='gform_page_5_1' class='gform_page' >\n                                    <div class='gform_page_fields'><ul id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below'><li id='field_5_13'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><center><img decoding=\"async\" src=\"https:\/\/www.lenoxesthetics.com\/wp-content\/uploads\/2021\/02\/Screenshot-2021-02-16-at-7.59.31-PM.png\"><\/img><\/center><\/li><li id='field_5_2'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_5_2_3' >I<span class='gfield_required'>*<\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gfield_trigger_change' id='input_5_2'>\n                            \n                            <span id='input_5_2_3_container' class='name_first' >\n                                                    <input type='text' name='input_2.3' id='input_5_2_3' value='' aria-label='First name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_5_2_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_2_6_container' class='name_last' >\n                                                    <input type='text' name='input_2.6' id='input_5_2_6' value='' aria-label='Last name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_5_2_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><div class='gfield_description'><p>hereby authorize and direct Lenox Laser & Esthetics and its physicians, estheticians, employees and associates:<\/p><\/div><\/li><li id='field_5_4'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_4' ><span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_5_4' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><div class='gfield_description'><p>to perform Laser Hair removal using the Cool Glide or Pro Wave770. I understand that this procedure works on growing hairs and NOT on dormant hairs. For this reason, destruction of all hair follicles from any one treatment is unlikely, and I understand that I will require several treatments to obtain a significant, long-term reduction of hair growth. I also understand that some people may not experience complete hair loss even with multiple laser procedures.<\/p><\/div><\/li><li id='field_5_6'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_6' ><span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_5_6' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><div class='gfield_description'><p>to perform Laser Genesis Non-Ablative Skin Therapy on me. I understand that this procedure works to promote vibrant, healthy looking skin and combat the signs of aging.<\/p><\/div><\/li><li id='field_5_7'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_7' ><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_5_7' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><div class='gfield_description'><p>to perform Limelight IPL skin therapy for the treatment of facial telangiectasia, to diffuse redness and solar lentignes. I understand that continued sun exposure may complicate the procedure and cause skin damage. <\/p><\/div><\/li><li id='field_5_8'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_8' ><span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_5_8' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><div class='gfield_description'><p>to perform IPL Photo Skin Therapy for the treatment and reduction of brown pigmentation and sun\/ age spots. I understand that continued sun exposure may complicate the procedure and cause skin damage.<\/p><\/div><\/li><li id='field_5_9'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_9' ><span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_5_9' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><div class='gfield_description'><p>to perform TITAN Skin Tightening treatment for skin tightening. The TITAN procedure stimulates new collagen growth deep in the skin by thermal heating.<\/p><\/div><\/li><li id='field_5_11'  class='gfield gfield_html gfield_html_formatted field_sublabel_below field_description_below gfield_visibility_visible' ><p>It has been explained to me that a laser treatment is considered a cosmetic procedure, and that I am responsible for all costs associated with each procedure and payment is to be made in full at the time of each treatment.<\/p>\n<p>I agree that the following points have been discussed with me: (1) the potential benefits of the proposed procedure; (2) the possible alternative procedures; (3) the probability of success; (4) the reasonably anticipated consequences if the procedure(s) is not performed; (5) the most likely complications and risks involved with the proposed procedure(s) and subsequent healing period, including but not limited to, infection, crusting, scarring, re-growth of hair, change in skin color and\/or blistering and (5) post-treatment instructions.<\/p>\n<p>I am aware of the following possible experiences and risks with laser treatment, including but not limited to: DISCOMFORT: some discomfort may be experienced during laser treatment<\/p>\n<p>WOUND HEALING: Laser treatment can result in swelling, blistering, crusting, or flaking of the treated areas, which may require one to three weeks to heal. Once the surface has healed, it may be pink or sensitive to the sun for an additional two to four weeks, or longer in some patients. I understand that I should remain out of the sun and use sun block during this healing period.<\/p>\n<p>BRUISING\/ SWELLING\/ INFECTION: With some laser treatments, bruising of the treated area may occur. Additionally, there may be some swelling noted. Finally, skin infection is a possibility although rare, whenever a laser skin procedure is performed.<\/p>\n<p>PIGMENT (SKIN COLOR) CHANGES: During the healing process, there is possibility that the treated area may become either LIGHTER or DARKER in color compared to the surrounding skin. This is usually temporary, but on rare occasion it may be permanent.<\/p>\n<p>SCARRING: scarring is a rare occurrence, but it is a possibility when the skins surface is disrupted. To minimize the chances of scarring, it is VERY IMPORTANT that I follow all post-treatment instructions. Such post-treatment instructions have been explained to me.<\/p>\n<p>EYE EXPOSURE: protective eyewear (shields) will be provided during the treatment. It is important to keep these shields on at all times during the treatment in order to protect my eyes from accidental laser exposure.\nI understand that any procedure performed by the Cutera Laser is inappropriate for individuals who (1) are pregnant; (2) are prone to keloid formation; (3) have a history of poor wound healing; (4) are taking medication which creates light sensitivity; (5) are taking anti-seizure medication; (6) are hypersensitive to light; (7) have a personal or family history of skin cancer; (8) have undiagnosed lesions; (9) had a recent herpetic outbreak; (10) have unstable diabetes or an auto-immune disorder and (11) have a photosensitive skin disorder.<\/p>\n<h3><center><b><u>ACKNOWLEDGEMENT<\/b><\/u><center><\/h3>\n<p>I UNDERSTAND AND ACKNOLEDGE THAT PAYMENTS FOR THE LASER PRECEDURES ARE NON-REFUNDABLE.<\/p>\n<p>BY MY SIGNATURE BELOW, I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS PERMISSION FORM FOR LASER TREATMENT AND THAT DISCLOSURES REFFERED TO HEREIN WERE MADE TO ME. I HEREBY RELEASE LENOX LASER & ESTHETICS FROM ANY AND ALL POTENTIAL CLAIMS, LIABILITIES AND DAMAGES THAT MAY RESULT FROM LASER PROCEDURES.<\/p><\/li><li id='field_5_12'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_12' >Date<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_12' id='input_5_12' type='text' value='' class='datepicker medium dmy datepicker_no_icon'   \/>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_12' class='gform_hidden' value='https:\/\/www.lenoxesthetics.com\/wp-content\/plugins\/gravityforms\/images\/calendar.png'\/><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer'>\n                         <input type='button' id='gform_next_button_5_14' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"2\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"2\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_2' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_5_2' class='gform_fields top_label form_sublabel_below description_below'><li id='field_5_15'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><center><img decoding=\"async\" src=\"https:\/\/www.lenoxesthetics.com\/wp-content\/uploads\/2021\/02\/Screenshot-2021-02-16-at-8.42.16-PM.png\"><\/img><\/center><\/li><li id='field_5_16'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><center>\n<h3><b>LASER TREATMENT CONSULTATION<\/b><\/h3>\n<\/center><\/li><li id='field_5_17'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_5_17_3' >Full Name<span class='gfield_required'>*<\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gfield_trigger_change' id='input_5_17'>\n                            \n                            <span id='input_5_17_3_container' class='name_first' >\n                                                    <input type='text' name='input_17.3' id='input_5_17_3' value='' aria-label='First name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_5_17_3' >First<\/label>\n                                                <\/span>\n                            <span id='input_5_17_4_container' class='name_middle' >\n                                                    <input type='text' name='input_17.4' id='input_5_17_4' value='' aria-label='Middle name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_5_17_4' >Middle<\/label>\n                                                <\/span>\n                            <span id='input_5_17_6_container' class='name_last' >\n                                                    <input type='text' name='input_17.6' id='input_5_17_6' value='' aria-label='Last name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_5_17_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id='field_5_18'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_18' >Date<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_18' id='input_5_18' type='text' value='' class='datepicker medium dmy datepicker_no_icon'   \/>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_18' class='gform_hidden' value='https:\/\/www.lenoxesthetics.com\/wp-content\/plugins\/gravityforms\/images\/calendar.png'\/><\/li><li id='field_5_19'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_19' >Primary skin concerns<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_5_19' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_20'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_20' >Past medical\/ surgery history<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_5_20' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_21'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_21' >Current medications<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_5_21' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_22'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_22' >Allergies<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_5_22' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_24'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_24' >Untitled<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_5_24' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_25'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Accutane (within last 12 months)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_25'><li class='gchoice_5_25_0'><input name='input_25' type='radio' value='NO'  id='choice_5_25_0'   onclick='gf_apply_rules(5,[26]);' onkeypress='gf_apply_rules(5,[26]);'  \/><label for='choice_5_25_0' id='label_5_25_0'>NO<\/label><\/li><li class='gchoice_5_25_1'><input name='input_25' type='radio' value='YES'  id='choice_5_25_1'   onclick='gf_apply_rules(5,[26]);' onkeypress='gf_apply_rules(5,[26]);'  \/><label for='choice_5_25_1' id='label_5_25_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_5_26'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_26' >Date of last exposure\/ medication<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_5_26' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_27'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Antibiotics (within last 7 days)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_27'><li class='gchoice_5_27_0'><input name='input_27' type='radio' value='NO'  id='choice_5_27_0'   onclick='gf_apply_rules(5,[28]);' onkeypress='gf_apply_rules(5,[28]);'  \/><label for='choice_5_27_0' id='label_5_27_0'>NO<\/label><\/li><li class='gchoice_5_27_1'><input name='input_27' type='radio' value='YES'  id='choice_5_27_1'   onclick='gf_apply_rules(5,[28]);' onkeypress='gf_apply_rules(5,[28]);'  \/><label for='choice_5_27_1' id='label_5_27_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_5_28'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_28' >Date of last exposure\/ medication<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_5_28' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_29'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Coagulation Problems<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_29'><li class='gchoice_5_29_0'><input name='input_29' type='radio' value='NO'  id='choice_5_29_0'   onclick='gf_apply_rules(5,[30]);' onkeypress='gf_apply_rules(5,[30]);'  \/><label for='choice_5_29_0' id='label_5_29_0'>NO<\/label><\/li><li class='gchoice_5_29_1'><input name='input_29' type='radio' value='YES'  id='choice_5_29_1'   onclick='gf_apply_rules(5,[30]);' onkeypress='gf_apply_rules(5,[30]);'  \/><label for='choice_5_29_1' id='label_5_29_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_5_30'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_30' >Date of last exposure\/ medication<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_5_30' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_32'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Cold sores\/ Herpes on treatment area<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_32'><li class='gchoice_5_32_0'><input name='input_32' type='radio' value='NO'  id='choice_5_32_0'   onclick='gf_apply_rules(5,[33]);' onkeypress='gf_apply_rules(5,[33]);'  \/><label for='choice_5_32_0' id='label_5_32_0'>NO<\/label><\/li><li class='gchoice_5_32_1'><input name='input_32' type='radio' value='YES'  id='choice_5_32_1'   onclick='gf_apply_rules(5,[33]);' onkeypress='gf_apply_rules(5,[33]);'  \/><label for='choice_5_32_1' id='label_5_32_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_5_33'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_33' >Date of last exposure\/ medication<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_5_33' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_34'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Diabetes<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_34'><li class='gchoice_5_34_0'><input name='input_34' type='radio' value='NO'  id='choice_5_34_0'   onclick='gf_apply_rules(5,[35]);' onkeypress='gf_apply_rules(5,[35]);'  \/><label for='choice_5_34_0' id='label_5_34_0'>NO<\/label><\/li><li class='gchoice_5_34_1'><input name='input_34' type='radio' value='YES'  id='choice_5_34_1'   onclick='gf_apply_rules(5,[35]);' onkeypress='gf_apply_rules(5,[35]);'  \/><label for='choice_5_34_1' id='label_5_34_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_5_35'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_35' >Date of last exposure\/ medication<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_5_35' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_36'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Gold Therapy<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_36'><li class='gchoice_5_36_0'><input name='input_36' type='radio' value='NO'  id='choice_5_36_0'   onclick='gf_apply_rules(5,[37]);' onkeypress='gf_apply_rules(5,[37]);'  \/><label for='choice_5_36_0' id='label_5_36_0'>NO<\/label><\/li><li class='gchoice_5_36_1'><input name='input_36' type='radio' value='YES'  id='choice_5_36_1'   onclick='gf_apply_rules(5,[37]);' onkeypress='gf_apply_rules(5,[37]);'  \/><label for='choice_5_36_1' id='label_5_36_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_5_37'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_37' >Date of last exposure\/ medication<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_5_37' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_38'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Skin cancer(s)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_38'><li class='gchoice_5_38_0'><input name='input_38' type='radio' value='NO'  id='choice_5_38_0'   onclick='gf_apply_rules(5,[39]);' onkeypress='gf_apply_rules(5,[39]);'  \/><label for='choice_5_38_0' id='label_5_38_0'>NO<\/label><\/li><li class='gchoice_5_38_1'><input name='input_38' type='radio' value='YES'  id='choice_5_38_1'   onclick='gf_apply_rules(5,[39]);' onkeypress='gf_apply_rules(5,[39]);'  \/><label for='choice_5_38_1' id='label_5_38_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_5_39'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_39' >Date of last exposure\/ medication<\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_5_39' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_40'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Keloids\/excessive scarring<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_40'><li class='gchoice_5_40_0'><input name='input_40' type='radio' value='NO'  id='choice_5_40_0'   onclick='gf_apply_rules(5,[41]);' onkeypress='gf_apply_rules(5,[41]);'  \/><label for='choice_5_40_0' id='label_5_40_0'>NO<\/label><\/li><li class='gchoice_5_40_1'><input name='input_40' type='radio' value='YES'  id='choice_5_40_1'   onclick='gf_apply_rules(5,[41]);' onkeypress='gf_apply_rules(5,[41]);'  \/><label for='choice_5_40_1' id='label_5_40_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_5_41'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_41' >Date of last exposure\/ medication<\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_5_41' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_42'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Pacemaker<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_42'><li class='gchoice_5_42_0'><input name='input_42' type='radio' value='NO'  id='choice_5_42_0'   onclick='gf_apply_rules(5,[43]);' onkeypress='gf_apply_rules(5,[43]);'  \/><label for='choice_5_42_0' id='label_5_42_0'>NO<\/label><\/li><li class='gchoice_5_42_1'><input name='input_42' type='radio' value='YES'  id='choice_5_42_1'   onclick='gf_apply_rules(5,[43]);' onkeypress='gf_apply_rules(5,[43]);'  \/><label for='choice_5_42_1' id='label_5_42_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_5_43'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_43' >Date of last exposure\/ medication<\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_5_43' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_44'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Photosensitive drugs (within last 4 weeks)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_44'><li class='gchoice_5_44_0'><input name='input_44' type='radio' value='NO'  id='choice_5_44_0'   onclick='gf_apply_rules(5,[45]);' onkeypress='gf_apply_rules(5,[45]);'  \/><label for='choice_5_44_0' id='label_5_44_0'>NO<\/label><\/li><li class='gchoice_5_44_1'><input name='input_44' type='radio' value='YES'  id='choice_5_44_1'   onclick='gf_apply_rules(5,[45]);' onkeypress='gf_apply_rules(5,[45]);'  \/><label for='choice_5_44_1' id='label_5_44_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_5_45'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_45' >Date of last exposure\/ medication<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_5_45' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_46'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Pregnancy<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_46'><li class='gchoice_5_46_0'><input name='input_46' type='radio' value='NO'  id='choice_5_46_0'   onclick='gf_apply_rules(5,[47]);' onkeypress='gf_apply_rules(5,[47]);'  \/><label for='choice_5_46_0' id='label_5_46_0'>NO<\/label><\/li><li class='gchoice_5_46_1'><input name='input_46' type='radio' value='YES'  id='choice_5_46_1'   onclick='gf_apply_rules(5,[47]);' onkeypress='gf_apply_rules(5,[47]);'  \/><label for='choice_5_46_1' id='label_5_46_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_5_47'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_47' >Date of last exposure\/ medication<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_5_47' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_48'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Retinoids on treatment area (within last 3 days)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_48'><li class='gchoice_5_48_0'><input name='input_48' type='radio' value='NO'  id='choice_5_48_0'   onclick='gf_apply_rules(5,[49]);' onkeypress='gf_apply_rules(5,[49]);'  \/><label for='choice_5_48_0' id='label_5_48_0'>NO<\/label><\/li><li class='gchoice_5_48_1'><input name='input_48' type='radio' value='YES'  id='choice_5_48_1'   onclick='gf_apply_rules(5,[49]);' onkeypress='gf_apply_rules(5,[49]);'  \/><label for='choice_5_48_1' id='label_5_48_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_5_49'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_49' >Date of last exposure\/ medication<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_5_49' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_50'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Eczema<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_50'><li class='gchoice_5_50_0'><input name='input_50' type='radio' value='NO'  id='choice_5_50_0'   onclick='gf_apply_rules(5,[51]);' onkeypress='gf_apply_rules(5,[51]);'  \/><label for='choice_5_50_0' id='label_5_50_0'>NO<\/label><\/li><li class='gchoice_5_50_1'><input name='input_50' type='radio' value='YES'  id='choice_5_50_1'   onclick='gf_apply_rules(5,[51]);' onkeypress='gf_apply_rules(5,[51]);'  \/><label for='choice_5_50_1' id='label_5_50_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_5_51'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_51' >Date of last exposure\/ medication<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_5_51' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_52'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Epilepsy\/ Seizures<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_52'><li class='gchoice_5_52_0'><input name='input_52' type='radio' value='NO'  id='choice_5_52_0'   onclick='gf_apply_rules(5,[53]);' onkeypress='gf_apply_rules(5,[53]);'  \/><label for='choice_5_52_0' id='label_5_52_0'>NO<\/label><\/li><li class='gchoice_5_52_1'><input name='input_52' type='radio' value='YES'  id='choice_5_52_1'   onclick='gf_apply_rules(5,[53]);' onkeypress='gf_apply_rules(5,[53]);'  \/><label for='choice_5_52_1' id='label_5_52_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_5_53'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_53' >Date of last exposure\/ medication<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_5_53' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_54'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3>IF YOU HAVE ANSWERED \u201cYES\u201d TO ANY OF THE ABOVE QUESTIONS, ACCORDING TO OUR MEDICAL DIRECTOR YOU MUST WAIT UNTIL AFTER THE PRESCRIBED PERIOD (WHERE APPLICABLE) AND\/ OR OBTAIN THE APPROVAL OF A PHYSICIAN PRIOR TO TREATMENT.<br><br>\nFor our information, we would also like to know if you have had any of the following:<\/h3><\/li><li id='field_5_55'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Chemical peels<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_55'><li class='gchoice_5_55_0'><input name='input_55' type='radio' value='NO'  id='choice_5_55_0'   onclick='gf_apply_rules(5,[56]);' onkeypress='gf_apply_rules(5,[56]);'  \/><label for='choice_5_55_0' id='label_5_55_0'>NO<\/label><\/li><li class='gchoice_5_55_1'><input name='input_55' type='radio' value='YES'  id='choice_5_55_1'   onclick='gf_apply_rules(5,[56]);' onkeypress='gf_apply_rules(5,[56]);'  \/><label for='choice_5_55_1' id='label_5_55_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_5_56'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_56' >Date of last exposure\/ medication<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_5_56' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_57'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Microdermabrasion on treatment area<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_57'><li class='gchoice_5_57_0'><input name='input_57' type='radio' value='NO'  id='choice_5_57_0'   onclick='gf_apply_rules(5,[58]);' onkeypress='gf_apply_rules(5,[58]);'  \/><label for='choice_5_57_0' id='label_5_57_0'>NO<\/label><\/li><li class='gchoice_5_57_1'><input name='input_57' type='radio' value='YES'  id='choice_5_57_1'   onclick='gf_apply_rules(5,[58]);' onkeypress='gf_apply_rules(5,[58]);'  \/><label for='choice_5_57_1' id='label_5_57_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_5_58'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_58' >Date of last exposure\/ medication<\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_5_58' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_59'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Botox\/ Restylane on treatment area<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_59'><li class='gchoice_5_59_0'><input name='input_59' type='radio' value='NO'  id='choice_5_59_0'   onclick='gf_apply_rules(5,[60]);' onkeypress='gf_apply_rules(5,[60]);'  \/><label for='choice_5_59_0' id='label_5_59_0'>NO<\/label><\/li><li class='gchoice_5_59_1'><input name='input_59' type='radio' value='YES'  id='choice_5_59_1'   onclick='gf_apply_rules(5,[60]);' onkeypress='gf_apply_rules(5,[60]);'  \/><label for='choice_5_59_1' id='label_5_59_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_5_60'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_60' >Date of last exposure\/ medication<\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_5_60' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_61'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Implants in treatment area<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_61'><li class='gchoice_5_61_0'><input name='input_61' type='radio' value='NO'  id='choice_5_61_0'   onclick='gf_apply_rules(5,[62]);' onkeypress='gf_apply_rules(5,[62]);'  \/><label for='choice_5_61_0' id='label_5_61_0'>NO<\/label><\/li><li class='gchoice_5_61_1'><input name='input_61' type='radio' value='YES'  id='choice_5_61_1'   onclick='gf_apply_rules(5,[62]);' onkeypress='gf_apply_rules(5,[62]);'  \/><label for='choice_5_61_1' id='label_5_61_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_5_62'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_62' >Date of last exposure\/ medication<\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_5_62' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_63'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Perm Lip\/ Collagen<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_63'><li class='gchoice_5_63_0'><input name='input_63' type='radio' value='NO'  id='choice_5_63_0'   onclick='gf_apply_rules(5,[64]);' onkeypress='gf_apply_rules(5,[64]);'  \/><label for='choice_5_63_0' id='label_5_63_0'>NO<\/label><\/li><li class='gchoice_5_63_1'><input name='input_63' type='radio' value='YES'  id='choice_5_63_1'   onclick='gf_apply_rules(5,[64]);' onkeypress='gf_apply_rules(5,[64]);'  \/><label for='choice_5_63_1' id='label_5_63_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_5_64'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_64' >Date of last exposure\/ medication<\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_5_64' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_65'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Previous laser treatment<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_65'><li class='gchoice_5_65_0'><input name='input_65' type='radio' value='NO'  id='choice_5_65_0'   onclick='gf_apply_rules(5,[66]);' onkeypress='gf_apply_rules(5,[66]);'  \/><label for='choice_5_65_0' id='label_5_65_0'>NO<\/label><\/li><li class='gchoice_5_65_1'><input name='input_65' type='radio' value='YES'  id='choice_5_65_1'   onclick='gf_apply_rules(5,[66]);' onkeypress='gf_apply_rules(5,[66]);'  \/><label for='choice_5_65_1' id='label_5_65_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_5_66'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_66' >Date of last exposure\/ medication<\/label><div class='ginput_container ginput_container_text'><input name='input_66' id='input_5_66' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_67'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Suntan\/ Self Tanner on treatment area<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_67'><li class='gchoice_5_67_0'><input name='input_67' type='radio' value='NO'  id='choice_5_67_0'   onclick='gf_apply_rules(5,[68]);' onkeypress='gf_apply_rules(5,[68]);'  \/><label for='choice_5_67_0' id='label_5_67_0'>NO<\/label><\/li><li class='gchoice_5_67_1'><input name='input_67' type='radio' value='YES'  id='choice_5_67_1'   onclick='gf_apply_rules(5,[68]);' onkeypress='gf_apply_rules(5,[68]);'  \/><label for='choice_5_67_1' id='label_5_67_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_5_68'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_68' >Date of last exposure\/ medication<\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_5_68' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_69'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Tattoos on treatment area<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_69'><li class='gchoice_5_69_0'><input name='input_69' type='radio' value='NO'  id='choice_5_69_0'   onclick='gf_apply_rules(5,[70]);' onkeypress='gf_apply_rules(5,[70]);'  \/><label for='choice_5_69_0' id='label_5_69_0'>NO<\/label><\/li><li class='gchoice_5_69_1'><input name='input_69' type='radio' value='YES'  id='choice_5_69_1'   onclick='gf_apply_rules(5,[70]);' onkeypress='gf_apply_rules(5,[70]);'  \/><label for='choice_5_69_1' id='label_5_69_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_5_70'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_70' >Date of last exposure\/ medication<\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_5_70' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_71'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Vitiligo<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_71'><li class='gchoice_5_71_0'><input name='input_71' type='radio' value='NO'  id='choice_5_71_0'   onclick='gf_apply_rules(5,[72]);' onkeypress='gf_apply_rules(5,[72]);'  \/><label for='choice_5_71_0' id='label_5_71_0'>NO<\/label><\/li><li class='gchoice_5_71_1'><input name='input_71' type='radio' value='YES'  id='choice_5_71_1'   onclick='gf_apply_rules(5,[72]);' onkeypress='gf_apply_rules(5,[72]);'  \/><label for='choice_5_71_1' id='label_5_71_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_5_72'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_72' >Date of last exposure\/ medication<\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_5_72' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_73'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Waxing on treatment area<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_73'><li class='gchoice_5_73_0'><input name='input_73' type='radio' value='NO'  id='choice_5_73_0'   onclick='gf_apply_rules(5,[74]);' onkeypress='gf_apply_rules(5,[74]);'  \/><label for='choice_5_73_0' id='label_5_73_0'>NO<\/label><\/li><li class='gchoice_5_73_1'><input name='input_73' type='radio' value='YES'  id='choice_5_73_1'   onclick='gf_apply_rules(5,[74]);' onkeypress='gf_apply_rules(5,[74]);'  \/><label for='choice_5_73_1' id='label_5_73_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_5_74'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_74' >Date of last exposure\/ medication<\/label><div class='ginput_container ginput_container_text'><input name='input_74' id='input_5_74' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_75'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3>PATIENT HAS RECEIVED VERBAL AND A COPY OF PRE\/POST TREATMENT INSTRUCTIONS.ALL BENEFITS, RISKS, PROBABILITY OF SUCCESS AND ALTERNATE PROCEDURES HAVE BEEN REVIEWED.<\/h3><\/li><li id='field_5_76'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_76' >Date<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_76' id='input_5_76' type='text' value='' class='datepicker medium dmy datepicker_no_icon'   \/>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_76' class='gform_hidden' value='https:\/\/www.lenoxesthetics.com\/wp-content\/plugins\/gravityforms\/images\/calendar.png'\/><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer'>\n                        <input type='button' id='gform_previous_button_5_77' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"1\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"1\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_5_77' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"3\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"3\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n 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gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_5_80_3' >Full Name<span class='gfield_required'>*<\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gfield_trigger_change' id='input_5_80'>\n                            \n                            <span id='input_5_80_3_container' class='name_first' >\n                                                    <input type='text' name='input_80.3' id='input_5_80_3' value='' aria-label='First name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_5_80_3' >First<\/label>\n                                                <\/span>\n                            <span id='input_5_80_4_container' class='name_middle' >\n                                                    <input type='text' name='input_80.4' id='input_5_80_4' value='' aria-label='Middle name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_5_80_4' >Middle<\/label>\n                                                <\/span>\n                            <span id='input_5_80_6_container' class='name_last' >\n                                                    <input type='text' name='input_80.6' id='input_5_80_6' value='' aria-label='Last name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_5_80_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id='field_5_81'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_81' >Date Of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_81' id='input_5_81' type='text' value='' class='datepicker medium dmy datepicker_no_icon'   \/>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_81' class='gform_hidden' value='https:\/\/www.lenoxesthetics.com\/wp-content\/plugins\/gravityforms\/images\/calendar.png'\/><\/li><li id='field_5_82'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_82' >1. I HAVE \/ HAVE NOT waxed or tweezed within 1 month prior to laser treatment.<\/label><div class='ginput_container ginput_container_text'><input name='input_82' id='input_5_82' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_83'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_83' >2. I HAVE \/ HAVE NOT taken antibiotics within 7 days prior to laser treatment.<\/label><div class='ginput_container ginput_container_text'><input name='input_83' id='input_5_83' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_84'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_84' >3. I HAVE \/ HAVE NOT used self tanners\/spray tans within 2 weeks prior to laser treatment.<\/label><div class='ginput_container ginput_container_text'><input name='input_84' id='input_5_84' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_85'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_85' >4. I HAVE \/ HAVE NOT used any RETINOL\/ BENZYOL PEROXIDE containing products within 7 days prior to laser treatment.<\/label><div class='ginput_container ginput_container_text'><input name='input_85' id='input_5_85' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_5_86'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_5_86' >5. 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