{"id":2387,"date":"2024-01-29T14:15:47","date_gmt":"2024-01-29T22:15:47","guid":{"rendered":"https:\/\/o2-wellness.com\/?page_id=2387"},"modified":"2024-01-29T14:19:28","modified_gmt":"2024-01-29T22:19:28","slug":"new-client-packet","status":"publish","type":"page","link":"https:\/\/o2-wellness.com\/new-client-packet\/","title":{"rendered":"New Client Packet"},"content":{"rendered":"<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_chrome gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_2' style='display:none'><div id='gf_2' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">New Client Packet<\/h2>\n                            <p class='gform_description'>Thank you for choosing O2 Wellness. We are thrilled to have the opportunity to assist you in meeting your goals.<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/wp-json\/wp\/v2\/pages\/2387#gf_2' data-formid='2' novalidate><div id='gf_page_steps_2' class='gf_page_steps'><div id='gf_step_2_1' class='gf_step gf_step_active gf_step_first'><span class='gf_step_number'>1<\/span><span class='gf_step_label'>Page 1<\/span><\/div><div id='gf_step_2_2' class='gf_step gf_step_last gf_step_next gf_step_pending'><span class='gf_step_number'>2<\/span><span class='gf_step_label'>Page 2<\/span><\/div><\/div> \r\n <input type='hidden' class='gforms-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/>\n                        <div class='gform-body gform_body'><div id='gform_page_2_1' class='gform_page ' data-js='page-field-id-1' >\n                                    <div class='gform_page_fields'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_above'><div id=\"field_2_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_1\" ><label class='gfield_label gform-field-label' for='input_2_1'>First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_2_1' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_12\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_12\" ><label class='gfield_label gform-field-label' for='input_2_12'>Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_2_12' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_3\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_3\" ><label class='gfield_label gform-field-label' for='input_2_3'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_2_3' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_4\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_4\" ><label class='gfield_label gform-field-label' for='input_2_4'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_4' id='input_2_4' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_2_5\" class=\"gfield gfield--type-address gfield--input-type-address field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_5\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_2_5' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_2_5_1_container' >\n                                        <input type='text' name='input_5.1' id='input_2_5_1' value=''    aria-required='false'    \/>\n                                        <label for='input_2_5_1' id='input_2_5_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_2_5_3_container' >\n                                    <input type='text' name='input_5.3' id='input_2_5_3' value=''    aria-required='false'    \/>\n                                    <label for='input_2_5_3' id='input_2_5_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_2_5_4_container' >\n                                        <select name='input_5.4' id='input_2_5_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_2_5_4' id='input_2_5_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_2_5_5_container' >\n                                    <input type='text' name='input_5.5' id='input_2_5_5' value=''    aria-required='false'    \/>\n                                    <label for='input_2_5_5' id='input_2_5_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_5.6' id='input_2_5_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_2_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_6\" ><label class='gfield_label gform-field-label' for='input_2_6'>Referred By<\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_2_6' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_7\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-half field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_7\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Date of Birth<\/legend><div id='input_2_7' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_2_7_1_container'>\n                                            <input type='number' maxlength='2' name='input_7[]' id='input_2_7_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_2_7_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_2_7_2_container'>\n                                            <input type='number' maxlength='2' name='input_7[]' id='input_2_7_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_2_7_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_2_7_3_container'>\n                                            <input type='number' maxlength='4' name='input_7[]' id='input_2_7_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2025' step='1'\/>\n                                            <label for='input_2_7_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_2_13\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_13\" ><label class='gfield_label gform-field-label' for='input_2_13'>Emergency Contact<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_2_13' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_14\" ><label class='gfield_label gform-field-label' for='input_2_14'>Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_2_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_15\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_15\" ><label class='gfield_label gform-field-label' for='input_2_15'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_15' id='input_2_15' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_19\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_3col_vertical field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_19\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Current Health Issues<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_19'><div class='gchoice gchoice_2_19_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.1' type='checkbox'  value='Acid Reflex'  id='choice_2_19_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_19_1' id='label_2_19_1' class='gform-field-label gform-field-label--type-inline'>Acid Reflex<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_19_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.2' type='checkbox'  value='Allergies'  id='choice_2_19_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_19_2' id='label_2_19_2' class='gform-field-label gform-field-label--type-inline'>Allergies<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_19_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.3' type='checkbox'  value='Anxiety'  id='choice_2_19_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_19_3' id='label_2_19_3' class='gform-field-label gform-field-label--type-inline'>Anxiety<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_19_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.4' type='checkbox'  value='Arthritis\/Osteoporosis'  id='choice_2_19_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_19_4' id='label_2_19_4' class='gform-field-label gform-field-label--type-inline'>Arthritis\/Osteoporosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_19_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.5' type='checkbox'  value='Asthma\/Lung Conditions'  id='choice_2_19_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_19_5' id='label_2_19_5' class='gform-field-label gform-field-label--type-inline'>Asthma\/Lung Conditions<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_19_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.6' type='checkbox'  value='Bloating'  id='choice_2_19_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_19_6' id='label_2_19_6' class='gform-field-label gform-field-label--type-inline'>Bloating<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_19_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.7' type='checkbox'  value='Brittle\/Hair Loss'  id='choice_2_19_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_19_7' id='label_2_19_7' class='gform-field-label gform-field-label--type-inline'>Brittle\/Hair Loss<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_19_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.8' type='checkbox'  value='Cancer'  id='choice_2_19_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_19_8' id='label_2_19_8' class='gform-field-label gform-field-label--type-inline'>Cancer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_19_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.9' type='checkbox'  value='Constipation'  id='choice_2_19_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_19_9' id='label_2_19_9' class='gform-field-label gform-field-label--type-inline'>Constipation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_19_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.11' type='checkbox'  value='Dehydration'  id='choice_2_19_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_19_11' id='label_2_19_11' class='gform-field-label gform-field-label--type-inline'>Dehydration<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_19_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.12' type='checkbox'  value='Depression'  id='choice_2_19_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_19_12' id='label_2_19_12' class='gform-field-label gform-field-label--type-inline'>Depression<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_19_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.13' type='checkbox'  value='Fatigue\/Lack of Energy'  id='choice_2_19_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_19_13' id='label_2_19_13' class='gform-field-label gform-field-label--type-inline'>Fatigue\/Lack of Energy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_19_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.14' type='checkbox'  value='Fibromyalgia'  id='choice_2_19_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_19_14' id='label_2_19_14' class='gform-field-label gform-field-label--type-inline'>Fibromyalgia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_19_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.15' type='checkbox'  value='Gout'  id='choice_2_19_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_19_15' id='label_2_19_15' class='gform-field-label gform-field-label--type-inline'>Gout<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_19_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.16' type='checkbox'  value='Headaches\/Migraines'  id='choice_2_19_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_19_16' id='label_2_19_16' class='gform-field-label gform-field-label--type-inline'>Headaches\/Migraines<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_19_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.17' type='checkbox'  value='Heavy Metals'  id='choice_2_19_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_19_17' id='label_2_19_17' class='gform-field-label gform-field-label--type-inline'>Heavy Metals<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_19_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.18' type='checkbox'  value='IBS'  id='choice_2_19_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_19_18' id='label_2_19_18' class='gform-field-label gform-field-label--type-inline'>IBS<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_19_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.19' type='checkbox'  value='Immune System'  id='choice_2_19_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_19_19' id='label_2_19_19' class='gform-field-label gform-field-label--type-inline'>Immune System<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_19_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.21' type='checkbox'  value='Incontinence'  id='choice_2_19_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_19_21' id='label_2_19_21' class='gform-field-label gform-field-label--type-inline'>Incontinence<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_19_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.22' type='checkbox'  value='Menopausal symptoms'  id='choice_2_19_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_19_22' id='label_2_19_22' class='gform-field-label gform-field-label--type-inline'>Menopausal symptoms<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_19_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.23' type='checkbox'  value='MS'  id='choice_2_19_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_19_23' id='label_2_19_23' class='gform-field-label gform-field-label--type-inline'>MS<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_19_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.24' type='checkbox'  value='Muscle\/Joint Inflammation'  id='choice_2_19_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_19_24' id='label_2_19_24' class='gform-field-label gform-field-label--type-inline'>Muscle\/Joint Inflammation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_19_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.25' type='checkbox'  value='Muscle cramps'  id='choice_2_19_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_19_25' id='label_2_19_25' class='gform-field-label gform-field-label--type-inline'>Muscle cramps<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_19_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.26' type='checkbox'  value='Overweight'  id='choice_2_19_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_19_26' id='label_2_19_26' class='gform-field-label gform-field-label--type-inline'>Overweight<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_19_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.27' type='checkbox'  value='Peripheral neuropathy'  id='choice_2_19_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_19_27' id='label_2_19_27' class='gform-field-label gform-field-label--type-inline'>Peripheral neuropathy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_19_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.28' type='checkbox'  value='Recovery of surgery\/trauma'  id='choice_2_19_28'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_19_28' id='label_2_19_28' class='gform-field-label gform-field-label--type-inline'>Recovery of surgery\/trauma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_19_29'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.29' type='checkbox'  value='Restless leg syndrome'  id='choice_2_19_29'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_19_29' id='label_2_19_29' class='gform-field-label gform-field-label--type-inline'>Restless leg syndrome<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_19_31'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.31' type='checkbox'  value='Sinus Issues'  id='choice_2_19_31'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_19_31' id='label_2_19_31' class='gform-field-label gform-field-label--type-inline'>Sinus Issues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_19_32'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.32' type='checkbox'  value='Skin Conditions'  id='choice_2_19_32'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_19_32' id='label_2_19_32' class='gform-field-label gform-field-label--type-inline'>Skin Conditions<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_19_33'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.33' type='checkbox'  value='Sleep Apnea'  id='choice_2_19_33'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_19_33' id='label_2_19_33' class='gform-field-label gform-field-label--type-inline'>Sleep Apnea<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_19_34'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.34' type='checkbox'  value='Other'  id='choice_2_19_34'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_19_34' id='label_2_19_34' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_9\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_9\" ><label class='gfield_label gform-field-label' for='input_2_9'>Allergies:<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_2_9' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_16\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_16\" ><label class='gfield_label gform-field-label' for='input_2_16'>Skin Conditions:<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_2_16' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_17\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_17\" ><label class='gfield_label gform-field-label' for='input_2_17'>Other:<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_2_17' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_10\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_10\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Are you taking any medications?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_10'><div class='gchoice gchoice_2_10_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.1' type='checkbox'  value='Yes'  id='choice_2_10_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_10_1' id='label_2_10_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_10_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.2' type='checkbox'  value='No'  id='choice_2_10_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_10_2' id='label_2_10_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_18\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_18\" ><label class='gfield_label gform-field-label' for='input_2_18'>Please list:<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_2_18' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_2_20' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"2\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"2\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_2' class='gform_page' data-js='page-field-id-20' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_2' class='gform_fields top_label form_sublabel_below description_above'><div id=\"field_2_11\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_11\" ><h3 class=\"gsection_title\">RELEASE OF LIABILITY<\/h3><div class='gsection_description' id='gfield_description_2_11'>Information below must be read and signed\/initialed in order to take advantage of the services provided by O2-Wellness. Separate forms will be provided for facial \nTreatments. <strong>If any of the following conditions exist, we strongly advise consulting your physician prior to using our services. <\/strong>\n<\/div><\/div><fieldset id=\"field_2_21\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_2col_vertical field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_21\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Therapeutic Whole Body Vibration<\/legend><div class='gfield_description' id='gfield_description_2_21'>A doctor\u2019s release is required if any of these conditions apply to you. <\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_21'><div class='gchoice gchoice_2_21_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.1' type='checkbox'  value='Acute hernia, discopathy'  id='choice_2_21_1'   aria-describedby=\"gfield_description_2_21\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_2_21_1' id='label_2_21_1' class='gform-field-label gform-field-label--type-inline'>Acute hernia, discopathy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_21_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.2' type='checkbox'  value='Acute thrombosis\/ Clots'  id='choice_2_21_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_21_2' id='label_2_21_2' class='gform-field-label gform-field-label--type-inline'>Acute thrombosis\/ Clots<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_21_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.3' type='checkbox'  value='Cancer'  id='choice_2_21_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_21_3' id='label_2_21_3' class='gform-field-label gform-field-label--type-inline'>Cancer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_21_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.4' type='checkbox'  value='Epilepsy'  id='choice_2_21_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_21_4' id='label_2_21_4' class='gform-field-label gform-field-label--type-inline'>Epilepsy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_21_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.5' type='checkbox'  value='Existing retinal detachment or any predisposition to retinal detachment'  id='choice_2_21_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_21_5' id='label_2_21_5' class='gform-field-label gform-field-label--type-inline'>Existing retinal detachment or any predisposition to retinal detachment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_21_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.6' type='checkbox'  value='Gall bladder problems relating to lymphatic drainage'  id='choice_2_21_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_21_6' id='label_2_21_6' class='gform-field-label gform-field-label--type-inline'>Gall bladder problems relating to lymphatic drainage<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_21_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.7' type='checkbox'  value='Hip or knee implants'  id='choice_2_21_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_21_7' id='label_2_21_7' class='gform-field-label gform-field-label--type-inline'>Hip or knee implants<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_21_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.8' type='checkbox'  value='Pacemaker'  id='choice_2_21_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_21_8' id='label_2_21_8' class='gform-field-label gform-field-label--type-inline'>Pacemaker<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_21_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.9' type='checkbox'  value='Phlebitis'  id='choice_2_21_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_21_9' id='label_2_21_9' class='gform-field-label gform-field-label--type-inline'>Phlebitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_21_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.11' type='checkbox'  value='Pregnancy'  id='choice_2_21_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_21_11' id='label_2_21_11' class='gform-field-label gform-field-label--type-inline'>Pregnancy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_21_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.12' type='checkbox'  value='Recently placed IUDs, metal pins or plates'  id='choice_2_21_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_21_12' id='label_2_21_12' class='gform-field-label gform-field-label--type-inline'>Recently placed IUDs, metal pins or plates<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_21_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.13' type='checkbox'  value='Recent wounds from surgery'  id='choice_2_21_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_21_13' id='label_2_21_13' class='gform-field-label gform-field-label--type-inline'>Recent wounds from surgery<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_21_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.14' type='checkbox'  value='Retinal detachment'  id='choice_2_21_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_21_14' id='label_2_21_14' class='gform-field-label gform-field-label--type-inline'>Retinal detachment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_21_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.15' type='checkbox'  value='Risk of Pulmonary embolism'  id='choice_2_21_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_21_15' id='label_2_21_15' class='gform-field-label gform-field-label--type-inline'>Risk of Pulmonary embolism<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_21_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.16' type='checkbox'  value='Serious cardiovascular disease'  id='choice_2_21_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_21_16' id='label_2_21_16' class='gform-field-label gform-field-label--type-inline'>Serious cardiovascular disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_21_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.17' type='checkbox'  value='Severe diabetes'  id='choice_2_21_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_21_17' id='label_2_21_17' class='gform-field-label gform-field-label--type-inline'>Severe diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_21_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.18' type='checkbox'  value='Severe migraine'  id='choice_2_21_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_21_18' id='label_2_21_18' class='gform-field-label gform-field-label--type-inline'>Severe migraine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_21_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.19' type='checkbox'  value='Tumors'  id='choice_2_21_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_21_19' id='label_2_21_19' class='gform-field-label gform-field-label--type-inline'>Tumors<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_21_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.21' type='checkbox'  value='None of the Above'  id='choice_2_21_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_21_21' id='label_2_21_21' class='gform-field-label gform-field-label--type-inline'>None of the Above<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_22\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_22\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Bemer Mat &amp; Body Balance<\/legend><div class='gfield_description' id='gfield_description_2_22'>Bemer Mat SHOULD NOT BE USED if any of the following apply to you<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_22'><div class='gchoice gchoice_2_22_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.1' type='checkbox'  value='Organ Transplant Recipients'  id='choice_2_22_1'   aria-describedby=\"gfield_description_2_22\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_1' id='label_2_22_1' class='gform-field-label gform-field-label--type-inline'>Organ Transplant Recipients<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.2' type='checkbox'  value='Heart Conditions, Heart Stent (OK to use on Level 1 no Plus)'  id='choice_2_22_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_2' id='label_2_22_2' class='gform-field-label gform-field-label--type-inline'>Heart Conditions, Heart Stent (OK to use on Level 1 no Plus)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.3' type='checkbox'  value='Blood Thinner Medication'  id='choice_2_22_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_3' id='label_2_22_3' class='gform-field-label gform-field-label--type-inline'>Blood Thinner Medication<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.4' type='checkbox'  value='Metal Implants'  id='choice_2_22_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_4' id='label_2_22_4' class='gform-field-label gform-field-label--type-inline'>Metal Implants<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.5' type='checkbox'  value='Pregnant'  id='choice_2_22_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_5' id='label_2_22_5' class='gform-field-label gform-field-label--type-inline'>Pregnant<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.6' type='checkbox'  value='None of the Above'  id='choice_2_22_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_6' id='label_2_22_6' class='gform-field-label gform-field-label--type-inline'>None of the Above<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_23\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_2col_vertical field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_23\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Oxygen Therapy &amp; O2 Magic Hydration Booth<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_23'><div class='gchoice gchoice_2_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='Allergies to metals'  id='choice_2_23_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_23_1' id='label_2_23_1' class='gform-field-label gform-field-label--type-inline'>Allergies to metals<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_23_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.2' type='checkbox'  value='Asthma'  id='choice_2_23_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_23_2' id='label_2_23_2' class='gform-field-label gform-field-label--type-inline'>Asthma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_23_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.3' type='checkbox'  value='Breathing Disorders \u2013 COPD'  id='choice_2_23_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_23_3' id='label_2_23_3' class='gform-field-label gform-field-label--type-inline'>Breathing Disorders \u2013 COPD<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_23_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.4' type='checkbox'  value='Epilepsy'  id='choice_2_23_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_23_4' id='label_2_23_4' class='gform-field-label gform-field-label--type-inline'>Epilepsy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_23_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.5' type='checkbox'  value='Heavy Metal Toxicity'  id='choice_2_23_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_23_5' id='label_2_23_5' class='gform-field-label gform-field-label--type-inline'>Heavy Metal Toxicity<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_23_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.6' type='checkbox'  value='Pregnancy'  id='choice_2_23_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_23_6' id='label_2_23_6' class='gform-field-label gform-field-label--type-inline'>Pregnancy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_23_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.7' type='checkbox'  value='None of the Above'  id='choice_2_23_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_23_7' id='label_2_23_7' class='gform-field-label gform-field-label--type-inline'>None of the Above<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_28\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_28\" ><label class='gfield_label gform-field-label' for='input_2_28'>Metal Allergies:<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_2_28' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_29\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_29\" ><label class='gfield_label gform-field-label' for='input_2_29'>Wet or Dry COPD?<\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_2_29' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_24\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_2col_vertical field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_24\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Med Bed<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_24'><div class='gchoice gchoice_2_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='Acute hyperthyroidism'  id='choice_2_24_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_24_1' id='label_2_24_1' class='gform-field-label gform-field-label--type-inline'>Acute hyperthyroidism<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value='Cardiac Arrhythmia'  id='choice_2_24_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_24_2' id='label_2_24_2' class='gform-field-label gform-field-label--type-inline'>Cardiac Arrhythmia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_24_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.3' type='checkbox'  value='Electronic Implants such as Pacemaker, insulin pumps, etc)'  id='choice_2_24_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_24_3' id='label_2_24_3' class='gform-field-label gform-field-label--type-inline'>Electronic Implants such as Pacemaker, insulin pumps, etc)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_24_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.4' type='checkbox'  value='Epilepsy'  id='choice_2_24_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_24_4' id='label_2_24_4' class='gform-field-label gform-field-label--type-inline'>Epilepsy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_24_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.5' type='checkbox'  value='Oversensitivity to EMS'  id='choice_2_24_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_24_5' id='label_2_24_5' class='gform-field-label gform-field-label--type-inline'>Oversensitivity to EMS<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_24_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.6' type='checkbox'  value='Pregnancy'  id='choice_2_24_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_24_6' id='label_2_24_6' class='gform-field-label gform-field-label--type-inline'>Pregnancy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_24_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.7' type='checkbox'  value='Tumor Illnesses'  id='choice_2_24_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_24_7' id='label_2_24_7' class='gform-field-label gform-field-label--type-inline'>Tumor Illnesses<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_24_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.8' type='checkbox'  value='None of the Above'  id='choice_2_24_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_24_8' id='label_2_24_8' class='gform-field-label gform-field-label--type-inline'>None of the Above<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_25\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_2col_vertical field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_25\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >O2 Sculpt<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_25'><div class='gchoice gchoice_2_25_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.1' type='checkbox'  value='Electronic Implants (such as Pacemaker, insulin pumps, etc)'  id='choice_2_25_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_25_1' id='label_2_25_1' class='gform-field-label gform-field-label--type-inline'>Electronic Implants (such as Pacemaker, insulin pumps, etc)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_25_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.2' type='checkbox'  value='Metal Implants'  id='choice_2_25_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_25_2' id='label_2_25_2' class='gform-field-label gform-field-label--type-inline'>Metal Implants<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_25_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.3' type='checkbox'  value='Pregnant or Breastfeeding'  id='choice_2_25_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_25_3' id='label_2_25_3' class='gform-field-label gform-field-label--type-inline'>Pregnant or Breastfeeding<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_25_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.4' type='checkbox'  value='None of the Above'  id='choice_2_25_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_25_4' id='label_2_25_4' class='gform-field-label gform-field-label--type-inline'>None of the Above<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_26\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_2col_vertical field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_26\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Contour Light<\/legend><div class='gfield_description' id='gfield_description_2_26'>Conditions that prevent treatment:<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_26'><div class='gchoice gchoice_2_26_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.1' type='checkbox'  value='Cancer (active or within 1yr of remission)'  id='choice_2_26_1'   aria-describedby=\"gfield_description_2_26\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_2_26_1' id='label_2_26_1' class='gform-field-label gform-field-label--type-inline'>Cancer (active or within 1yr of remission)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_26_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.2' type='checkbox'  value='Hepatitis C or D'  id='choice_2_26_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_26_2' id='label_2_26_2' class='gform-field-label gform-field-label--type-inline'>Hepatitis C or D<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_26_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.3' type='checkbox'  value='Uncontrolled High Blood Pressure'  id='choice_2_26_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_26_3' id='label_2_26_3' class='gform-field-label gform-field-label--type-inline'>Uncontrolled High Blood Pressure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_26_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.4' type='checkbox'  value='HIV\/AIDS'  id='choice_2_26_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_26_4' id='label_2_26_4' class='gform-field-label gform-field-label--type-inline'>HIV\/AIDS<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_26_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.5' type='checkbox'  value='Pacemaker'  id='choice_2_26_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_26_5' id='label_2_26_5' class='gform-field-label gform-field-label--type-inline'>Pacemaker<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_26_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.6' type='checkbox'  value='Pregnant or Breastfeeding'  id='choice_2_26_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_26_6' id='label_2_26_6' class='gform-field-label gform-field-label--type-inline'>Pregnant or Breastfeeding<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_26_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.7' type='checkbox'  value='None of the Above'  id='choice_2_26_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_26_7' id='label_2_26_7' class='gform-field-label gform-field-label--type-inline'>None of the Above<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_27\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_2col_vertical field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_27\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Ionic Foot Detox<\/legend><div class='gfield_description' id='gfield_description_2_27'>The ionSpa Pro SHOULD NOT BE USED by:<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_27'><div class='gchoice gchoice_2_27_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.1' type='checkbox'  value='Metal Implants'  id='choice_2_27_1'   aria-describedby=\"gfield_description_2_27\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_2_27_1' id='label_2_27_1' class='gform-field-label gform-field-label--type-inline'>Metal Implants<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_27_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.2' type='checkbox'  value='Organ transplant recipients or using life sustaining medications'  id='choice_2_27_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_27_2' id='label_2_27_2' class='gform-field-label gform-field-label--type-inline'>Organ transplant recipients or using life sustaining medications<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_27_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.3' type='checkbox'  value='Persons with a Pacemaker'  id='choice_2_27_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_27_3' id='label_2_27_3' class='gform-field-label gform-field-label--type-inline'>Persons with a Pacemaker<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_27_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.4' type='checkbox'  value='Using a battery-operated, electrical implant or heart beat regulations meds'  id='choice_2_27_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_27_4' id='label_2_27_4' class='gform-field-label gform-field-label--type-inline'>Using a battery-operated, electrical implant or heart beat regulations meds<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_27_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.5' type='checkbox'  value='Pregnant woman and breast-feeding mothers'  id='choice_2_27_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_27_5' id='label_2_27_5' class='gform-field-label gform-field-label--type-inline'>Pregnant woman and breast-feeding mothers<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_27_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.6' type='checkbox'  value='None of the Above'  id='choice_2_27_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_27_6' id='label_2_27_6' class='gform-field-label gform-field-label--type-inline'>None of the Above<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_30\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_2col_vertical field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_30\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Infrared Sauna<\/legend><div class='gfield_description' id='gfield_description_2_30'>In all situations, hydration is a requirement for sauna use.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_30'><div class='gchoice gchoice_2_30_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.1' type='checkbox'  value='Alcohol\/Drug Abuse'  id='choice_2_30_1'   aria-describedby=\"gfield_description_2_30\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_1' id='label_2_30_1' class='gform-field-label gform-field-label--type-inline'>Alcohol\/Drug Abuse<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_30_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.2' type='checkbox'  value='Cardiovascular Conditions'  id='choice_2_30_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_2' id='label_2_30_2' class='gform-field-label gform-field-label--type-inline'>Cardiovascular Conditions<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_30_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.3' type='checkbox'  value='Chronic Conditions'  id='choice_2_30_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_3' id='label_2_30_3' class='gform-field-label gform-field-label--type-inline'>Chronic Conditions<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_30_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.4' type='checkbox'  value='Diseases Associated with a Reduced Ability to Sweat or Perspire'  id='choice_2_30_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_4' id='label_2_30_4' class='gform-field-label gform-field-label--type-inline'>Diseases Associated with a Reduced Ability to Sweat or Perspire<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_30_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.5' type='checkbox'  value='Fever'  id='choice_2_30_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_5' id='label_2_30_5' class='gform-field-label gform-field-label--type-inline'>Fever<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_30_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.6' type='checkbox'  value='Hemophiliacs'  id='choice_2_30_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_6' id='label_2_30_6' class='gform-field-label gform-field-label--type-inline'>Hemophiliacs<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_30_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.7' type='checkbox'  value='Implants'  id='choice_2_30_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_7' id='label_2_30_7' class='gform-field-label gform-field-label--type-inline'>Implants<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_30_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.8' type='checkbox'  value='Individuals Prone to Bleeding'  id='choice_2_30_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_8' id='label_2_30_8' class='gform-field-label gform-field-label--type-inline'>Individuals Prone to Bleeding<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_30_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.9' type='checkbox'  value='Insensitivity to Heat'  id='choice_2_30_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_9' id='label_2_30_9' class='gform-field-label gform-field-label--type-inline'>Insensitivity to Heat<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_30_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.11' type='checkbox'  value='Joint Injury'  id='choice_2_30_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_11' id='label_2_30_11' class='gform-field-label gform-field-label--type-inline'>Joint Injury<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_30_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.12' type='checkbox'  value='Medications'  id='choice_2_30_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_12' id='label_2_30_12' class='gform-field-label gform-field-label--type-inline'>Medications<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_30_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.13' type='checkbox'  value='Menstruation'  id='choice_2_30_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_13' id='label_2_30_13' class='gform-field-label gform-field-label--type-inline'>Menstruation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_30_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.14' type='checkbox'  value='Pacemaker\/Defibrillator'  id='choice_2_30_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_14' id='label_2_30_14' class='gform-field-label gform-field-label--type-inline'>Pacemaker\/Defibrillator<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_30_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.15' type='checkbox'  value='Pregnancy'  id='choice_2_30_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_15' id='label_2_30_15' class='gform-field-label gform-field-label--type-inline'>Pregnancy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_30_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.16' type='checkbox'  value='The Elderly'  id='choice_2_30_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_16' id='label_2_30_16' class='gform-field-label gform-field-label--type-inline'>The Elderly<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_30_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.17' type='checkbox'  value='None of the Above'  id='choice_2_30_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_17' id='label_2_30_17' class='gform-field-label gform-field-label--type-inline'>None of the Above<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_31\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_31\" ><p><strong>Please be aware of the following: <\/strong><\/p>\n<ul>\n<li> - Do not wear metal, operate a computer or use a cellular phone during an ionSpa Pro session. <\/li>\n<li> - Consult your physician prior to your ionSpa Pro session if you have any of the following conditions: diabetes, implants (including dental), congestive heart failure, or any other medical condition. <\/li>\n<li> - You must be properly hydrated prior to each ionSpa Pro session.<\/li>\n<\/ul>\n\n--------<\/div><div id=\"field_2_32\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_32\" ><p>By signing below, I have read and understand all of the contraindications for the Therapeutic Whole Body Vibration Machine, Infrared Sauna, Ionic Foot Detox, Lipo Light, Ultrasonic Cavitation\/RF, Oxygen Bar, and Body Balancing Therapy. <\/p>\n\n<p>I am using the Therapeutic Whole Body Vibration Machine, Infrared Sauna, Ionic Foot Detox, 10 Minute Face Lift, Oxygen Bar, Body Balancing Therapy, and the HCG diet drops and plan at my own risk and I understand it is my responsibility to inform O2-Wellness of any pre-existing medical condition. O2-Wellness will not be held responsible for causing or exacerbating any personal injury.<\/p>\n\n\n<p>I also acknowledge that the information and products provided by O2 Wellness website, informational packets, or employees is not a substitute for professional medical diagnosis or treatment by a licensed physician. Information and statements regarding our products are for informational purposes and have not been evaluated by the Food and Drug Administration (FDA) and are not intended to diagnose, treat, cure, or prevent any disease. I also understand that O2 Wellness encourages me to always seek the advice of my physician or other qualified health provider with any questions I may have regarding a medical condition. <\/p>\n\n<p>I hereby certify that I am in good physical condition and I am not aware of any physical infirmity that presents a risk with the services provided by O2 Wellness. None of the contraindications on this sheet apply to me. Should there be a change in my medical condition after signing this form, I agree to inform O2 Wellness and review the contraindications prior to using the aforementioned services.<\/p>\n\n<p>I am fully aware of the risks and hazards connected with the services provided by O2 Wellness.  I agree not to sue or bring any legal action against O2 Wellness, their employees, owners and agents, and I release all aforementioned parties from any and all liability claims, liens, or causes of action resulting from any damage, loss or injury (including death) while using their services, regardless of the cause of such loss, injury or damage. I acknowledge and understand that this is my responsibility to Inform O2 Wellness to any pre-existing medical condition or injury. O2 Wellness will not be held responsible for the causing or exacerbating of any personal injury, and are therefore held harmless. <\/p>\n<\/div><div id=\"field_2_33\" class=\"gfield gfield--type-signature gfield--input-type-signature field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_2_33\" ><label class='gfield_label gform-field-label' for='input_2_33'>Signature<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_2_33_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_2_33_valid' id='input_2_33_valid' \/><canvas id='input_2_33' width='300' height='180'><\/canvas><\/div><\/div><\/div><\/div><\/div>\n        <div class='gform_page_footer top_label'><input type='submit' id='gform_previous_button_2' class='gform_previous_button gform-theme-button 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