{"id":9,"date":"2020-07-22T00:13:19","date_gmt":"2020-07-22T04:13:19","guid":{"rendered":"http:\/\/myskincareclub.com\/forms\/?page_id=9"},"modified":"2020-10-29T18:04:29","modified_gmt":"2020-10-29T22:04:29","slug":"general-health-form","status":"publish","type":"page","link":"https:\/\/myskincareclub.com\/forms\/general-health-form\/","title":{"rendered":"GENERAL HEALTH FORM"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"9\" class=\"elementor elementor-9\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-671c6007 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"671c6007\" data-element_type=\"section\" data-e-type=\"section\">\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-219615af\" data-id=\"219615af\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-a34b3f3 elementor-widget elementor-widget-heading\" data-id=\"a34b3f3\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">GENERAL HEALTH FORM<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-3c802c40 elementor-widget elementor-widget-text-editor\" data-id=\"3c802c40\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\n<p><div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_2_container\" >\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_js_validate  frm_ajax_submit  frm_pro_form \" id=\"form_generalhealthform\" >\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">#2-GENERAL HEALTH FORM<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"2\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_2\" id=\"frm_hide_fields_2\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"generalhealthform\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_2\" name=\"frm_submit_entry_2\" value=\"7304d70deb\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/forms\/wp-json\/wp\/v2\/pages\/9\" \/><div id=\"frm_field_6_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_49gl2\" id=\"field_49gl2_label\" class=\"frm_primary_label\">First Name\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_49gl2\" name=\"item_meta[6]\" value=\"\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_7_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_8rf5m\" id=\"field_8rf5m_label\" class=\"frm_primary_label\">Last Name\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_8rf5m\" name=\"item_meta[7]\" value=\"\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_84_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_vo5ao\" id=\"field_vo5ao_label\" class=\"frm_primary_label\">Street Address\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_vo5ao\" name=\"item_meta[84]\" value=\"\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_85_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_10mi3\" id=\"field_10mi3_label\" class=\"frm_primary_label\">City:\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_10mi3\" name=\"item_meta[85]\" value=\"\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_86_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_8kbbr\" id=\"field_8kbbr_label\" class=\"frm_primary_label\">Province\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_8kbbr\" name=\"item_meta[86]\" value=\"\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_87_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_debzy\" id=\"field_debzy_label\" class=\"frm_primary_label\">Postal Code:\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_debzy\" name=\"item_meta[87]\" value=\"\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_9_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_zis0u\" id=\"field_zis0u_label\" class=\"frm_primary_label\">Home Phone\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_zis0u\" name=\"item_meta[9]\" value=\"\"  data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_10_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_u2n3i\" id=\"field_u2n3i_label\" class=\"frm_primary_label\">Business Phone\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_u2n3i\" name=\"item_meta[10]\" value=\"\"  data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_jtdft\" id=\"field_jtdft_label\" class=\"frm_primary_label\">Cell\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_jtdft\" name=\"item_meta[11]\" value=\"\"  data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_12_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_m8zg5\" id=\"field_m8zg5_label\" class=\"frm_primary_label\">Email\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_m8zg5\" name=\"item_meta[12]\" value=\"\"  data-invmsg=\"Email is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_13_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_n8p99\" id=\"field_n8p99_label\" class=\"frm_primary_label\">Date of Birth\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_n8p99\" name=\"item_meta[13]\" value=\"\"  maxlength=\"10\" data-invmsg=\"Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_14_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_aysqq\" id=\"field_aysqq_label\" class=\"frm_primary_label\">Name and Address of Family Physician\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_aysqq\" name=\"item_meta[14]\" value=\"\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_15_container\" class=\"frm_form_field form-field  frm_top_container horizontal_radio\">\r\n    <div  id=\"field_ws230_label\" class=\"frm_primary_label\">Do we need to be discreet with messages?\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_ws230_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_15-0\">\t\t\t<label  for=\"field_ws230-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[15]\" id=\"field_ws230-0\" value=\"Yes\"\n\t\t data-invmsg=\"Do we need to be discreet with messages? is invalid\"   \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_15-1\">\t\t\t<label  for=\"field_ws230-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[15]\" id=\"field_ws230-1\" value=\"No\"\n\t\t data-invmsg=\"Do we need to be discreet with messages? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_16_container\" class=\"frm_form_field form-field  frm_inline_container horizontal_radio\">\r\n    <div  id=\"field_oob78_label\" class=\"frm_primary_label\">May we contact you via e-mail\/text message?\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_oob78_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_16-0\">\t\t\t<label  for=\"field_oob78-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[16]\" id=\"field_oob78-0\" value=\"Yes\"\n\t\t data-invmsg=\"May we contact you via e-mail\/text message? is invalid\"   \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_16-1\">\t\t\t<label  for=\"field_oob78-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[16]\" id=\"field_oob78-1\" value=\"No\"\n\t\t data-invmsg=\"May we contact you via e-mail\/text message? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_17_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n    <div  id=\"field_guvtx_label\" class=\"frm_primary_label\">Female patients: Are you or could you be pregnant or nursing?\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_guvtx_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_17-0\">\t\t\t<label  for=\"field_guvtx-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[17]\" id=\"field_guvtx-0\" value=\"Yes\"\n\t\t data-invmsg=\"Female patients: Are you or could you be pregnant or nursing? is invalid\"   \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_17-1\">\t\t\t<label  for=\"field_guvtx-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[17]\" id=\"field_guvtx-1\" value=\"No\"\n\t\t data-invmsg=\"Female patients: Are you or could you be pregnant or nursing? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_18_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n    <div  id=\"field_inrbj_label\" class=\"frm_primary_label\">Do you experience easy or excessive bruising\/ bleeding?\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_inrbj_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_18-0\">\t\t\t<label  for=\"field_inrbj-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[18]\" id=\"field_inrbj-0\" value=\"Yes\"\n\t\t data-invmsg=\"Do you experience easy or excessive bruising\/ bleeding? is invalid\"   \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_18-1\">\t\t\t<label  for=\"field_inrbj-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[18]\" id=\"field_inrbj-1\" value=\"No\"\n\t\t data-invmsg=\"Do you experience easy or excessive bruising\/ bleeding? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_19_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n    <div  id=\"field_3giph_label\" class=\"frm_primary_label\">Have you had any reaction to any type of anesthetic- dental\/surgery?\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_3giph_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_19-0\">\t\t\t<label  for=\"field_3giph-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[19]\" id=\"field_3giph-0\" value=\"Yes\"\n\t\t data-invmsg=\"Have you had any reaction to any type of anesthetic- dental\/surgery? is invalid\"   \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_19-1\">\t\t\t<label  for=\"field_3giph-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[19]\" id=\"field_3giph-1\" value=\"No\"\n\t\t data-invmsg=\"Have you had any reaction to any type of anesthetic- dental\/surgery? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_20_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n    <div  id=\"field_h7fx_label\" class=\"frm_primary_label\">Do you or any family member suffer from the following neurological disorders:\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_h7fx_label\" role=\"group\"><\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_98_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n    <div  id=\"field_d19l_label\" class=\"frm_primary_label\">Amyotrophic Lateral Sclerosis (ALS)\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_d19l_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_98-0\">\t\t\t<label  for=\"field_d19l-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[98]\" id=\"field_d19l-0\" value=\"Yes\"\n\t\t data-invmsg=\"Amyotrophic Lateral Sclerosis (ALS) is invalid\"   \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_98-1\">\t\t\t<label  for=\"field_d19l-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[98]\" id=\"field_d19l-1\" value=\"No\"\n\t\t data-invmsg=\"Amyotrophic Lateral Sclerosis (ALS) is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_99_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n    <div  id=\"field_ab4s8_label\" class=\"frm_primary_label\">Myasthenia Gravis\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_ab4s8_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_99-0\">\t\t\t<label  for=\"field_ab4s8-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[99]\" id=\"field_ab4s8-0\" value=\"Yes\"\n\t\t data-invmsg=\"Myasthenia Gravis is invalid\"   \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_99-1\">\t\t\t<label  for=\"field_ab4s8-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[99]\" id=\"field_ab4s8-1\" value=\"No\"\n\t\t data-invmsg=\"Myasthenia Gravis is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_100_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n    <div  id=\"field_hdiju_label\" class=\"frm_primary_label\">Lambert Eaton Syndrome\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_hdiju_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_100-0\">\t\t\t<label  for=\"field_hdiju-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[100]\" id=\"field_hdiju-0\" value=\"Yes\"\n\t\t data-invmsg=\"Lambert Eaton Syndrome is invalid\"   \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_100-1\">\t\t\t<label  for=\"field_hdiju-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[100]\" id=\"field_hdiju-1\" value=\"No\"\n\t\t data-invmsg=\"Lambert Eaton Syndrome is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_21_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n    <div  id=\"field_ffglw_label\" class=\"frm_primary_label\">Do you have any semi-permeant filler in your face (Bio-Alcamid, Dermalive, Dermadeep, Beauticall, Artecoll, or Artesense)?\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_ffglw_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_21-0\">\t\t\t<label  for=\"field_ffglw-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[21]\" id=\"field_ffglw-0\" value=\"Yes\"\n\t\t data-invmsg=\"Do you have any semi-permeant filler in your face (Bio-Alcamid, Dermalive, Dermadeep, Beauticall, Artecoll, or Artesense)? is invalid\"   \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_21-1\">\t\t\t<label  for=\"field_ffglw-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[21]\" id=\"field_ffglw-1\" value=\"No\"\n\t\t data-invmsg=\"Do you have any semi-permeant filler in your face (Bio-Alcamid, Dermalive, Dermadeep, Beauticall, Artecoll, or Artesense)? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_22_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_c2skw\" id=\"field_c2skw_label\" class=\"frm_primary_label\">Describe\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_c2skw\" name=\"item_meta[22]\" value=\"\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_23_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n    <div  id=\"field_prpfh_label\" class=\"frm_primary_label\">Select if you have or have had any issues with the following:\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_prpfh_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-0\">\t\t\t<label  for=\"field_prpfh-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_prpfh-0\" value=\"Eczema\"  data-invmsg=\"Select if you have or have had any issues with the following: is invalid\"   \/> Eczema<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-1\">\t\t\t<label  for=\"field_prpfh-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_prpfh-1\" value=\"Acne\"  data-invmsg=\"Select if you have or have had any issues with the following: is invalid\"   \/> Acne<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-2\">\t\t\t<label  for=\"field_prpfh-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_prpfh-2\" value=\"Keloid Formation\"  data-invmsg=\"Select if you have or have had any issues with the following: is invalid\"   \/> Keloid Formation<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-3\">\t\t\t<label  for=\"field_prpfh-3\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_prpfh-3\" value=\"Laser therapy\"  data-invmsg=\"Select if you have or have had any issues with the following: is invalid\"   \/> Laser therapy<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-4\">\t\t\t<label  for=\"field_prpfh-4\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_prpfh-4\" value=\"Chemical Peels\"  data-invmsg=\"Select if you have or have had any issues with the following: is invalid\"   \/> Chemical Peels<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-5\">\t\t\t<label  for=\"field_prpfh-5\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_prpfh-5\" value=\"Dermabrasion\"  data-invmsg=\"Select if you have or have had any issues with the following: is invalid\"   \/> Dermabrasion<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-6\">\t\t\t<label  for=\"field_prpfh-6\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_prpfh-6\" value=\"Herpes\/Cold Sores\"  data-invmsg=\"Select if you have or have had any issues with the following: is invalid\"   \/> Herpes\/Cold Sores<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_24_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_g0qq0\" id=\"field_g0qq0_label\" class=\"frm_primary_label\">Last outbreak?\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_g0qq0\" name=\"item_meta[24]\" value=\"\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_25_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n    <div  id=\"field_wpoc4_label\" class=\"frm_primary_label\">Select any of the following which you presently have or have had:\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_wpoc4_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-0\">\t\t\t<label  for=\"field_wpoc4-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-0\" value=\"Cancer\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Cancer<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-1\">\t\t\t<label  for=\"field_wpoc4-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-1\" value=\"Diabetes\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Diabetes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-2\">\t\t\t<label  for=\"field_wpoc4-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-2\" value=\"Angina\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Angina<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-3\">\t\t\t<label  for=\"field_wpoc4-3\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-3\" value=\"Emphysema\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Emphysema<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-4\">\t\t\t<label  for=\"field_wpoc4-4\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-4\" value=\"Tuberculosis\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Tuberculosis<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-5\">\t\t\t<label  for=\"field_wpoc4-5\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-5\" value=\"Asthma Respiratory problems\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Asthma Respiratory problems<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-6\">\t\t\t<label  for=\"field_wpoc4-6\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-6\" value=\"Thyroid Disease\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Thyroid Disease<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-7\">\t\t\t<label  for=\"field_wpoc4-7\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-7\" value=\"Migraines Headaches\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Migraines Headaches<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-8\">\t\t\t<label  for=\"field_wpoc4-8\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-8\" value=\"Seizures Epilepsy\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Seizures Epilepsy<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-9\">\t\t\t<label  for=\"field_wpoc4-9\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-9\" value=\"Stroke\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Stroke<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-10\">\t\t\t<label  for=\"field_wpoc4-10\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-10\" value=\"Lupus\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Lupus<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-11\">\t\t\t<label  for=\"field_wpoc4-11\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-11\" value=\"High Blood Pressure\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> High Blood Pressure<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-12\">\t\t\t<label  for=\"field_wpoc4-12\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-12\" value=\"Heart Murmur\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Heart Murmur<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-13\">\t\t\t<label  for=\"field_wpoc4-13\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-13\" value=\"Rheumatic Fever\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Rheumatic Fever<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-14\">\t\t\t<label  for=\"field_wpoc4-14\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-14\" value=\"Mitral Valve Prolaps\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Mitral Valve Prolaps<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-15\">\t\t\t<label  for=\"field_wpoc4-15\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-15\" value=\"Congenital Heart Defect\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Congenital Heart Defect<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-16\">\t\t\t<label  for=\"field_wpoc4-16\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-16\" value=\"Pacemaker\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Pacemaker<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-17\">\t\t\t<label  for=\"field_wpoc4-17\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-17\" value=\"Artificial Valve Joint or Prosthesis\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Artificial Valve Joint or Prosthesis<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-18\">\t\t\t<label  for=\"field_wpoc4-18\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-18\" value=\"Hirsutism excessive hair growth\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Hirsutism excessive hair growth<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-19\">\t\t\t<label  for=\"field_wpoc4-19\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-19\" value=\"Anemia\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Anemia<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-20\">\t\t\t<label  for=\"field_wpoc4-20\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-20\" value=\"Sickle Cell Disease\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Sickle Cell Disease<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-21\">\t\t\t<label  for=\"field_wpoc4-21\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-21\" value=\"Blood Transfusions in last 6 months\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Blood Transfusions in last 6 months<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-22\">\t\t\t<label  for=\"field_wpoc4-22\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-22\" value=\"Liver Disease\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Liver Disease<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-23\">\t\t\t<label  for=\"field_wpoc4-23\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-23\" value=\"Jaundice\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Jaundice<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-24\">\t\t\t<label  for=\"field_wpoc4-24\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-24\" value=\"Stomach Ulcer\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Stomach Ulcer<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-25\">\t\t\t<label  for=\"field_wpoc4-25\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-25\" value=\"Kidney Disease\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Kidney Disease<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-26\">\t\t\t<label  for=\"field_wpoc4-26\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-26\" value=\"Arthritis\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Arthritis<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-27\">\t\t\t<label  for=\"field_wpoc4-27\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-27\" value=\"Sinusitis\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Sinusitis<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-28\">\t\t\t<label  for=\"field_wpoc4-28\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-28\" value=\"Psychiatric Treatments\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Psychiatric Treatments<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-29\">\t\t\t<label  for=\"field_wpoc4-29\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-29\" value=\"Addiction Alcoholism\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Addiction Alcoholism<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-30\">\t\t\t<label  for=\"field_wpoc4-30\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-30\" value=\"Hepatitis\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Hepatitis<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-31\">\t\t\t<label  for=\"field_wpoc4-31\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-31\" value=\"Glaucoma\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Glaucoma<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-32\">\t\t\t<label  for=\"field_wpoc4-32\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-32\" value=\"HIV AIDS\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> HIV AIDS<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-33\">\t\t\t<label  for=\"field_wpoc4-33\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-33\" value=\"Warts\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Warts<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-34\">\t\t\t<label  for=\"field_wpoc4-34\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-34\" value=\"Recent Dental procedure\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Recent Dental procedure<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-35\">\t\t\t<label  for=\"field_wpoc4-35\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-35\" value=\"Skin Conditions\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Skin Conditions<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-36\">\t\t\t<label  for=\"field_wpoc4-36\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-36\" value=\"Skin Sensitivity to sun or other\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Skin Sensitivity to sun or other<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-37\">\t\t\t<label  for=\"field_wpoc4-37\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-37\" value=\"Metal Implants including IUD\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Metal Implants including IUD<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-38\">\t\t\t<label  for=\"field_wpoc4-38\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-38\" value=\"Blood Disorders bleeding clotting\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Blood Disorders bleeding clotting<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-39\">\t\t\t<label  for=\"field_wpoc4-39\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-39\" value=\"Oral Corticosteroids\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Oral Corticosteroids<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-40\">\t\t\t<label  for=\"field_wpoc4-40\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-40\" value=\"Fainting spells\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Fainting spells<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-41\">\t\t\t<label  for=\"field_wpoc4-41\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-41\" value=\"Radiation Chemotherapy in last 6 months\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> Radiation Chemotherapy in last 6 months<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_25-42\">\t\t\t<label  for=\"field_wpoc4-42\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[25][]\" id=\"field_wpoc4-42\" value=\"MS Bells Palsy\"  data-invmsg=\"Select any of the following which you presently have or have had: is invalid\"   \/> MS Bells Palsy<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_26_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n    <div  id=\"field_usbet_label\" class=\"frm_primary_label\">Do you have or had any other diseases or medical problems not listed on this form?\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_usbet_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_26-0\">\t\t\t<label  for=\"field_usbet-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[26]\" id=\"field_usbet-0\" value=\"Yes\"\n\t\t data-invmsg=\"Do you have or had any other diseases or medical problems not listed on this form? is invalid\"   \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_26-1\">\t\t\t<label  for=\"field_usbet-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[26]\" id=\"field_usbet-1\" value=\"No\"\n\t\t data-invmsg=\"Do you have or had any other diseases or medical problems not listed on this form? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_27_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_lzek0\" id=\"field_lzek0_label\" class=\"frm_primary_label\">Describe\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_lzek0\" name=\"item_meta[27]\" value=\"\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_28_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n    <div  id=\"field_4324z_label\" class=\"frm_primary_label\">Do you have any allergies?  If yes, please list using the category below:\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_4324z_label\" role=\"group\"><\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_149_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio frm_other_container\">\r\n    <div  id=\"field_mss22_label\" class=\"frm_primary_label\">\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_mss22_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_149-other_2\">\t\t\t<label  for=\"field_mss22-other_2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[149][other_2]\" id=\"field_mss22-other_2\" value=\"Medications\"  data-invmsg=\"This field is invalid\"   \/> Medications<\/label><label for=\"field_mss22-other_2-otext\" class=\"frm_screen_reader frm_hidden\">Medications<\/label><input type=\"text\" id=\"field_mss22-other_2-otext\" class=\"frm_other_input frm_pos_none\"  name=\"item_meta[other][149][other_2]\" value=\"\" \/><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_150_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio frm_other_container\">\r\n    <div  id=\"field_bwi3u_label\" class=\"frm_primary_label\">\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_bwi3u_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_150-other_2\">\t\t\t<label  for=\"field_bwi3u-other_2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[150][other_2]\" id=\"field_bwi3u-other_2\" value=\"Latex\/ Rubber products\"  data-invmsg=\"This field is invalid\"   \/> Latex\/ Rubber products<\/label><label for=\"field_bwi3u-other_2-otext\" class=\"frm_screen_reader frm_hidden\">Latex\/ Rubber products<\/label><input type=\"text\" id=\"field_bwi3u-other_2-otext\" class=\"frm_other_input frm_pos_none\"  name=\"item_meta[other][150][other_2]\" value=\"\" \/><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_151_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio frm_other_container\">\r\n    <div  id=\"field_goyvf_label\" class=\"frm_primary_label\">\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_goyvf_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_151-other_0\">\t\t\t<label  for=\"field_goyvf-other_0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[151][other_0]\" id=\"field_goyvf-other_0\" value=\"Bees\/Wasps\"  data-invmsg=\"This field is invalid\"   \/> Bees\/Wasps<\/label><label for=\"field_goyvf-other_0-otext\" class=\"frm_screen_reader frm_hidden\">Bees\/Wasps<\/label><input type=\"text\" id=\"field_goyvf-other_0-otext\" class=\"frm_other_input frm_pos_none\"  name=\"item_meta[other][151][other_0]\" value=\"\" \/><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_29_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n    <div  id=\"field_5x4xw_label\" class=\"frm_primary_label\">Have you been treated with Dysport, Botox or Xeomin?\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_5x4xw_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_29-0\">\t\t\t<label  for=\"field_5x4xw-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[29]\" id=\"field_5x4xw-0\" value=\"Yes\"\n\t\t data-invmsg=\"Have you been treated with Dysport, Botox or Xeomin? is invalid\"   \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_29-1\">\t\t\t<label  for=\"field_5x4xw-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[29]\" id=\"field_5x4xw-1\" value=\"No\"\n\t\t data-invmsg=\"Have you been treated with Dysport, Botox or Xeomin? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_30_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_lwxb9\" id=\"field_lwxb9_label\" class=\"frm_primary_label\">Date of last injection:\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_lwxb9\" name=\"item_meta[30]\" value=\"\"  maxlength=\"10\" data-invmsg=\"Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_31_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n    <div  id=\"field_ihnps_label\" class=\"frm_primary_label\">Have you been treated with Hyaluronic Acid Fillers?\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_ihnps_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_31-0\">\t\t\t<label  for=\"field_ihnps-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[31]\" id=\"field_ihnps-0\" value=\"Yes\"\n\t\t data-invmsg=\"Have you been treated with Hyaluronic Acid Fillers? is invalid\"   \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_31-1\">\t\t\t<label  for=\"field_ihnps-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[31]\" id=\"field_ihnps-1\" value=\"No\"\n\t\t data-invmsg=\"Have you been treated with Hyaluronic Acid Fillers? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_32_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_yd48c\" id=\"field_yd48c_label\" class=\"frm_primary_label\">Date of last injection:\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_yd48c\" name=\"item_meta[32]\" value=\"\"  maxlength=\"10\" data-invmsg=\"Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_33_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_x9crw\" id=\"field_x9crw_label\" class=\"frm_primary_label\">Have you ever experience any problems with the procedure:\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_x9crw\" name=\"item_meta[33]\" value=\"\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_34_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_7rfwh\" id=\"field_7rfwh_label\" class=\"frm_primary_label\">Please list prescription medications and vitamins currently taken:\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_7rfwh\" name=\"item_meta[34]\" value=\"\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_36_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n    <div  id=\"field_dnpb4_label\" class=\"frm_primary_label\">Do you smoke?\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_dnpb4_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_36-0\">\t\t\t<label  for=\"field_dnpb4-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[36]\" id=\"field_dnpb4-0\" value=\"Yes\"\n\t\t data-invmsg=\"Do you smoke? is invalid\"   \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_36-1\">\t\t\t<label  for=\"field_dnpb4-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[36]\" id=\"field_dnpb4-1\" value=\"No\"\n\t\t data-invmsg=\"Do you smoke? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_37_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_hbi8p\" id=\"field_hbi8p_label\" class=\"frm_primary_label\">How much do you smoke?\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_hbi8p\" name=\"item_meta[37]\" value=\"\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_39_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n    <div  id=\"field_p89q1_label\" class=\"frm_primary_label\">Do you consume alcohol?\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_p89q1_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_39-0\">\t\t\t<label  for=\"field_p89q1-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[39]\" id=\"field_p89q1-0\" value=\"Yes\"\n\t\t data-invmsg=\"Do you consume alcohol? is invalid\"   \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_39-1\">\t\t\t<label  for=\"field_p89q1-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[39]\" id=\"field_p89q1-1\" value=\"No\"\n\t\t data-invmsg=\"Do you consume alcohol? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_40_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_7g1\" id=\"field_7g1_label\" class=\"frm_primary_label\">How much alcohol do you consume?\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_7g1\" name=\"item_meta[40]\" value=\"\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_41_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_lja0r\" id=\"field_lja0r_label\" class=\"frm_primary_label\">Who referred you to us?\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_lja0r\" name=\"item_meta[41]\" value=\"\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_43_container\" class=\"frm_form_field  frm_html_container form-field\">I HEREBY ACKNOWLEDGE THAT I HAVE FULLY DISCLOSED, TO THE BEST OF MY KNOWLEDGE, MY COMPLETE MEDICAL HISTORY AND HAVE ANSWERED ALL OF THESE QUESTIONS AS HONESTLY AND COMPLETELY AS POSSIBLE. NEITHER THE NURSE PRACTITIONER, NOR THEIR NURSE, ARE RESPONSIBLE FOR ANY ADVERSE EVENTS THAT OCCUR AS A RESULT PF FAILURE TO DISCLOSE HEALTH INFORMATION AS REQUESTED.<Br><Br><\/p>\n<p>I acknowledge that I have had the opportunity to consult with the Nurse Practitioner to ask any questions that I may have related to the procedure I am about to undergo. The Nurse Practitioner has reviewed my health history and medications with me and I agree that I have not withheld any medical information from them or their associates.<br \/>\nI acknowledge that delegation of this injection to the Registered Nurse by the Nurse Practitioner.<\/p><\/div>\n<div id=\"frm_field_44_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_p2kkc\" id=\"field_p2kkc_label\" class=\"frm_primary_label\">Date\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_p2kkc\" name=\"item_meta[44]\" value=\"\"  maxlength=\"10\" data-invmsg=\"Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_46_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_qlchj\" id=\"field_qlchj_label\" class=\"frm_primary_label\">Patient Name\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_qlchj\" name=\"item_meta[46]\" value=\"\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_45_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_b0gsr\" id=\"field_b0gsr_label\" class=\"frm_primary_label\">Signature\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div class=\"sigPad\" id='sigPad45' style=\"max-width:400px;\">\n\t<div class=\"sig sigWrapper\" style=\"height:150px;border-color:#BFC3C8;--bg-color:#ffffff;--active:#579AF6;--inactive:#eaeaea;--active-text:#ffffff;--inactive-text:#3f4b5b;--button-margin:22px;--button-size:20px;--button-padding:10px;--button-side-margin:22px;--icon:20px\">\n\n\t\t<ul class=\"sigNav\">\n\t\t\t\t<li class=\"drawIt\">\n\t\t\t\t\t<a href=\"#\" class=\"frm-active-sig-type\" title=\"Draw It\" aria-label=\"Draw It\">\n\t\t\t\t\t\t<svg  viewBox=\"0 0 22 20\" class=\"frmsvg\">\n\t<title>signature<\/title>\n\t<path d=\"M19.7 2.2A3.5 3.5 0 0 0 14 1.1L1.7 13.4a1 1 0 0 0-.3.4l-1.3 5a.9.9 0 0 0 0 .5 1 1 0 0 0 1 .6l5-1.3c.2 0 .4-.1.5-.3L18.9 6a3.5 3.5 0 0 0 .7-3.8zm-6.8 2.6L15.2 7l-8.6 8.7-2.4-2.4zm-10.7 13l1-3.3L5.4 17zM18 4.2l-.4.5L16.3 6 14 3.7l1.3-1.3A1.7 1.7 0 0 1 18 3.6l-.1.6zM9 17.9h11v1H9v-1z\"><\/path>\n\n<\/svg>\t\t\t\t\t<\/a>\n\t\t\t\t<\/li>\n\t\t\t\t<li class=\"typeIt\">\n\t\t\t\t\t<a href=\"#\" class=\"\" title=\"Type It\" aria-label=\"Type It\">\n\t\t\t\t\t\t<svg  viewBox=\"0 0 22 20\" class=\"frmsvg\">\n\t<title>keyboard<\/title>\n\t<path d=\"M20.6 2.5H2c-1 0-1.9.8-1.9 1.9v11.2c0 1 .8 1.9 1.9 1.9h18.7c1 0 1.9-.8 1.9-1.9V4.4c0-1-.8-1.9-1.9-1.9zm.3 13.1c0 .2-.1.3-.3.3H2a.3.3 0 0 1-.3-.3V4.4c0-.2.1-.3.3-.3h18.7c.2 0 .3.1.3.3v11.2zm-14.3-5V9.4c0-.3-.2-.5-.4-.5H5c-.3 0-.5.2-.5.5v1c0 .3.2.5.5.5h1c.3 0 .5-.2.5-.5zm3.8 0V9.4c0-.3-.2-.5-.5-.5H9c-.3 0-.5.2-.5.5v1c0 .3.2.5.4.5H10c.3 0 .5-.2.5-.5zm3.7 0V9.4c0-.3-.2-.5-.4-.5h-1.1c-.3 0-.5.2-.5.5v1c0 .3.2.5.5.5h1c.3 0 .5-.2.5-.5zm3.8 0V9.4c0-.3-.2-.5-.5-.5h-1c-.3 0-.5.2-.5.5v1c0 .3.2.5.4.5h1.1c.3 0 .5-.2.5-.5zM4.8 7.2v-1c0-.3-.2-.5-.5-.5H3.2c-.3 0-.5.2-.5.4v1.1c0 .3.2.5.5.5h1.1c.3 0 .5-.2.5-.5zm3.7 0v-1c0-.3-.2-.5-.5-.5H7c-.3 0-.5.2-.5.4v1.1c0 .3.2.5.5.5h1c.3 0 .5-.2.5-.5zm3.8 0v-1c0-.3-.2-.5-.5-.5h-1.1c-.3 0-.5.2-.5.4v1.1c0 .3.2.5.5.5h1.1c.3 0 .5-.2.5-.5zm3.7 0v-1c0-.3-.2-.5-.5-.5h-1c-.3 0-.5.2-.5.4v1.1c0 .3.2.5.5.5h1c.3 0 .5-.2.5-.5zm3.8 0v-1c0-.3-.2-.5-.5-.5h-1.1c-.3 0-.5.2-.5.4v1.1c0 .3.2.5.5.5h1.1c.3 0 .5-.2.5-.5zm-2 6.2V13c0-.3-.2-.5-.6-.5h-12c-.3 0-.6.2-.6.5v.6c0 .3.3.5.7.5h12c.3 0 .6-.2.6-.5z\"><\/path>\n<\/svg>\t\t\t\t\t<\/a>\n\t\t\t\t<\/li>\n\t\t<\/ul>\n\n\t\t<span class=\"frm-typed-drawline\"><\/span>\n\n\t\t<div class=\"typed\">\n\t\t\t<input type=\"text\" name=\"item_meta[45][typed]\" class=\"name\" id=\"field_b0gsr\" autocomplete=\"off\" value=\"\"  style=\"width:400px\" maxlength=\"150\" class=\"auto_width\" aria-invalid=\"false\"   \/>\n\t\t<\/div>\n\n\t\t<canvas class=\"pad\" data-fieldid=\"45\" data-fieldname=\"item_meta[45]\" width=\"396\" height=\"150\"><\/canvas>\n\t\t<div class=\"clearButton\"><a href=\"#clear\">Clear<\/a><\/div>\n\n\t\t<input type=\"hidden\" name=\"item_meta[45][output]\" class=\"output\" value=\"\" \/>\n\t<\/div>\n<\/div>\n\r\n    \r\n    \r\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t<div id=\"frm_field_236_container\">\n\t\t\t<label for=\"field_nz8vl\" >\n\t\t\t\tIf you are human, leave this field blank.\t\t\t<\/label>\n\t\t\t<input  id=\"field_nz8vl\" type=\"text\" class=\"frm_form_field form-field frm_verify\" name=\"item_meta[236]\" value=\"\"  \/>\n\t\t<\/div>\n\t\t<input name=\"frm_state\" type=\"hidden\" value=\"xgbTmpRrvI+5BluaOEpLIlW8FjqijRFd0qTsRQYgnMNWd+qsW1JCJdlPXUnTGqYH\" \/><div class=\"frm_submit\">\r\n\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"   formnovalidate=\"formnovalidate\">Submit<\/button>\r\n\r\n<\/div><\/div>\n<\/fieldset>\n<\/div>\n\n<\/form>\n<\/div>\n<script>\nvar frmSigs=[{\"bgColour\":\"rgba(0,0,0,0)\",\"id\":\"45\",\"width\":\"400\",\"height\":\"150\",\"line_top\":105.5,\"line_margin\":20,\"line_color\":\"#BFC3C8\",\"line_width\":1,\"default_tab\":\"drawIt\",\"bg_color\":\"#ffffff\",\"text_color\":\"#555555\",\"border_color\":\"#BFC3C8\"}];\nif(typeof __FRMSIG === 'undefined'){__FRMSIG=frmSigs;}else{__FRMSIG=jQuery.extend(__FRMSIG,frmSigs);}\n<\/script>\n<\/p>\n\t\t\t\t\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<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>GENERAL HEALTH FORM<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_canvas","meta":{"footnotes":""},"class_list":["post-9","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/myskincareclub.com\/forms\/wp-json\/wp\/v2\/pages\/9","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/myskincareclub.com\/forms\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/myskincareclub.com\/forms\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/myskincareclub.com\/forms\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/myskincareclub.com\/forms\/wp-json\/wp\/v2\/comments?post=9"}],"version-history":[{"count":6,"href":"https:\/\/myskincareclub.com\/forms\/wp-json\/wp\/v2\/pages\/9\/revisions"}],"predecessor-version":[{"id":126,"href":"https:\/\/myskincareclub.com\/forms\/wp-json\/wp\/v2\/pages\/9\/revisions\/126"}],"wp:attachment":[{"href":"https:\/\/myskincareclub.com\/forms\/wp-json\/wp\/v2\/media?parent=9"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}