{"id":5821,"date":"2025-07-29T15:18:10","date_gmt":"2025-07-29T15:18:10","guid":{"rendered":"https:\/\/testv81.demowebsitelinks.com\/PEMFV2\/?page_id=5821"},"modified":"2025-09-19T13:55:10","modified_gmt":"2025-09-19T13:55:10","slug":"hydrogen-inhalation-therapy-client-intake-form","status":"publish","type":"page","link":"https:\/\/testv81.demowebsitelinks.com\/PEMFV2\/hydrogen-inhalation-therapy-client-intake-form\/","title":{"rendered":"Hydrogen Inhalation Therapy Client Intake Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"5821\" class=\"elementor elementor-5821\">\n\t\t\t\t        <section class=\"elementor-section elementor-top-section elementor-element elementor-element-a7e3908 elementor-section-stretched pxl-row-scroll-fixed elementor-section-boxed elementor-section-height-default elementor-section-height-default pxl-zoom-point-false pxl-section-overflow-visible pxl-section-fix-none pxl-bg-color-none pxl-section-overlay-none\" data-id=\"a7e3908\" data-element_type=\"section\" data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;,&quot;background_background&quot;:&quot;classic&quot;}\">\n\n                \n                <div class=\"elementor-container elementor-column-gap-extended \">\n                <div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-3a2650c pxl-column-sticky pxl-column-overflow-hidden-no\" data-id=\"3a2650c\" data-element_type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\r\n        <div class=\"elementor-widget-wrap elementor-element-populated\">\r\n                     \r\n        \t\t<div class=\"elementor-element elementor-element-49681da elementor-widget elementor-widget-heading\" data-id=\"49681da\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Client Intake Form<\/h2>\t\t\t\t<\/div>\n\t\t            <\/div>\r\n        <\/div>\r\n        \t\t\t<\/div>\n\t\t<\/section>\n\t\t        <section class=\"elementor-section elementor-top-section elementor-element elementor-element-2f9f2c5 elementor-section-stretched pxl-row-scroll-fixed elementor-section-boxed elementor-section-height-default elementor-section-height-default pxl-zoom-point-false pxl-section-overflow-visible pxl-section-fix-none pxl-bg-color-none pxl-section-overlay-none\" data-id=\"2f9f2c5\" data-element_type=\"section\" data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;}\">\n\n                \n                <div class=\"elementor-container elementor-column-gap-extended \">\n                <div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-188fad1 pxl-column-sticky pxl-column-overflow-hidden-no\" data-id=\"188fad1\" data-element_type=\"column\">\r\n        <div class=\"elementor-widget-wrap elementor-element-populated\">\r\n                     \r\n        \t\t<div class=\"elementor-element elementor-element-4c485b6 elementor-widget elementor-widget-shortcode\" data-id=\"4c485b6\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script type=\"text\/javascript\">var 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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_gecko gform_wrapper gravity-theme' id='gform_wrapper_1' style='display:none'><div id='gf_1' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_1' id='gform_1'  action='\/PEMFV2\/wp-json\/wp\/v2\/pages\/5821#gf_1' novalidate><div id='gf_page_steps_1' class='gf_page_steps'><div id='gf_step_1_1' class='gf_step gf_step_active gf_step_first'><span class='gf_step_number'>1<\/span><span class='gf_step_label'>1. 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Liability Waiver & Disclaimer<\/span><\/div><\/div>\n                        <div class='gform_body gform-body'><div id='gform_page_1_1' class='gform_page' >\n                                    <div class='gform_page_fields'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below'><fieldset id=\"field_1_3\"  class=\"gfield gfield--width-full field_sublabel_hidden_label field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_3\"><legend class='gfield_label gfield_label_before_complex'  >Full Name<\/legend><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name' id='input_1_3'>\n                            \n                            <span id='input_1_3_3_container' class='name_first' >\n                                                    <input type='text' name='input_3.3' id='input_1_3_3' value=''   aria-required='false'     \/>\n          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type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_13\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_13\"><label class='gfield_label' for='input_1_13' >Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_1_13' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_14\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_14\"><label class='gfield_label' for='input_1_14' >Phone:<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_1_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                     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class=\"gfield gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_17\"><\/div><div id=\"field_1_18\"  class=\"gfield gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_18\"><\/div><div id=\"field_1_19\"  class=\"gfield gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_19\"><\/div><fieldset id=\"field_1_20\"  class=\"gfield gfield--width-full chk-1 field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_20\"><legend class='gfield_label gfield_label_before_complex'  >Heart disease or pacemaker<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_20'><div class='gchoice gchoice_1_20_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.1' type='checkbox'  value=''  id='choice_1_20_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_20_1' id='label_1_20_1'><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_20_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.2' type='checkbox'  value=''  id='choice_1_20_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_20_2' id='label_1_20_2'><\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_21\"  class=\"gfield gfield--width-full chk-2 field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_21\"><legend class='gfield_label gfield_label_before_complex'  >Respiratory conditions (e.g. asthma, COPD)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_21'><div class='gchoice gchoice_1_21_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.1' type='checkbox'  value=''  id='choice_1_21_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_1' id='label_1_21_1'><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_21_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.2' type='checkbox'  value=''  id='choice_1_21_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_2' id='label_1_21_2'><\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_22\"  class=\"gfield gfield--width-full chk-3 field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_22\"><legend class='gfield_label gfield_label_before_complex'  >Seizure disorder<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_22'><div class='gchoice gchoice_1_22_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.1' type='checkbox'  value=''  id='choice_1_22_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_22_1' id='label_1_22_1'><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_22_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.2' type='checkbox'  value=''  id='choice_1_22_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_22_2' id='label_1_22_2'><\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_23\"  class=\"gfield gfield--width-full chk-4 field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_23\"><legend class='gfield_label gfield_label_before_complex'  >Pregnancy or breastfeeding<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_23'><div class='gchoice gchoice_1_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value=''  id='choice_1_23_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_1' id='label_1_23_1'><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_23_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.2' type='checkbox'  value=''  id='choice_1_23_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_23_2' id='label_1_23_2'><\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_24\"  class=\"gfield gfield--width-full chk-5 field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_24\"><legend class='gfield_label gfield_label_before_complex'  >Cancer or undergoing chemotherapy<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_24'><div class='gchoice gchoice_1_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value=''  id='choice_1_24_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_1' id='label_1_24_1'><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value=''  id='choice_1_24_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_2' id='label_1_24_2'><\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_25\"  class=\"gfield gfield--width-full chk-6 field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_25\"><legend class='gfield_label gfield_label_before_complex'  >Recent surgery or hospitalization<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_25'><div class='gchoice gchoice_1_25_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.1' type='checkbox'  value=''  id='choice_1_25_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_25_1' id='label_1_25_1'><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_25_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.2' type='checkbox'  value=''  id='choice_1_25_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_25_2' id='label_1_25_2'><\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_26\"  class=\"gfield gfield--width-full chk-7 field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_26\"><legend class='gfield_label gfield_label_before_complex'  >High or low blood pressure<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_26'><div class='gchoice gchoice_1_26_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.1' type='checkbox'  value=''  id='choice_1_26_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_26_1' id='label_1_26_1'><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_26_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.2' type='checkbox'  value=''  id='choice_1_26_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_26_2' id='label_1_26_2'><\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_27\"  class=\"gfield gfield--width-full chk-8 field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_27\"><legend class='gfield_label gfield_label_before_complex'  >Metal implants or medical devices<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_27'><div class='gchoice gchoice_1_27_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.1' type='checkbox'  value=''  id='choice_1_27_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_27_1' id='label_1_27_1'><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_27_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.2' type='checkbox'  value=''  id='choice_1_27_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_27_2' id='label_1_27_2'><\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_28\"  class=\"gfield gfield--width-full chk-9 field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_28\"><legend class='gfield_label gfield_label_before_complex'  >Current smoker or recent tobacco use<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_28'><div class='gchoice gchoice_1_28_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.1' type='checkbox'  value=''  id='choice_1_28_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_28_1' id='label_1_28_1'><\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_28_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.2' type='checkbox'  value=''  id='choice_1_28_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_28_2' id='label_1_28_2'><\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_30\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_30\"><label class='gfield_label' for='input_1_30' >Please list any allergies, including medications or substances:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_30' id='input_1_30' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_1_31\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_31\"><legend class='gfield_label gfield_label_before_complex'  >Are you currently taking any medications or supplements?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_31'><div class='gchoice gchoice_1_31_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.1' type='checkbox'  value='Yes'  id='choice_1_31_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_31_1' id='label_1_31_1'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_31_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.2' type='checkbox'  value='No'  id='choice_1_31_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_31_2' id='label_1_31_2'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_32\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_1_32\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_1_32' >If yes, please list:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_32' id='input_1_32' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_33' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"1\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"1\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_33' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_3' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_3' class='gform_fields top_label form_sublabel_below description_below'><fieldset id=\"field_1_34\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_34\"><legend class='gfield_label gfield_label_before_complex'  >What are your main reasons for trying Hydrogen Inhalation Therapy?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_34'><div class='gchoice gchoice_1_34_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.1' type='checkbox'  value='General wellness\/anti-aging'  id='choice_1_34_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_1' id='label_1_34_1'>General wellness\/anti-aging<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_34_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.2' type='checkbox'  value='Detoxification'  id='choice_1_34_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_2' id='label_1_34_2'>Detoxification<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_34_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.3' type='checkbox'  value='Detoxification'  id='choice_1_34_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_3' id='label_1_34_3'>Detoxification<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_34_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.4' type='checkbox'  value='Athletic recovery'  id='choice_1_34_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_4' id='label_1_34_4'>Athletic recovery<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_34_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.5' type='checkbox'  value='Energy boost'  id='choice_1_34_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_5' id='label_1_34_5'>Energy boost<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_34_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.6' type='checkbox'  value='Other'  id='choice_1_34_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_6' id='label_1_34_6'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_35\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below hidden_label gfield_visibility_hidden\"  data-js-reload=\"field_1_35\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_1_35' >Untitled<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_35' id='input_1_35' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_36' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_36' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"4\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"4\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_4' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_4' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_1_37\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_37\">____ I understand that Hydrogen Inhalation Therapy is not a substitute for medical diagnosis or treatment.\n____ I have disclosed all relevant health conditions to ensure safe application.\n____ I understand that while generally considered safe, hydrogen therapy may not be appropriate for everyone.\n____ I agree to communicate any discomfort or unusual sensations during the session.\n____ I give my voluntary consent to participate in hydrogen inhalation therapy.<\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_39' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_39' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"5\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"5\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_5' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_5' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_1_40\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_40\">I confirm that all information provided is accurate to the best of my knowledge.<\/div><div id=\"field_1_41\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_41\"><label class='gfield_label' for='input_1_41' >Client Signature<\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_1_41' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_42\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_42\"><label class='gfield_label' for='input_1_42' >Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_42' id='input_1_42' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_42_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_42_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_42' class='gform_hidden' value='https:\/\/testv81.demowebsitelinks.com\/PEMFV2\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_43\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_43\"><label class='gfield_label' for='input_1_43' >Staff Initials<\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_1_43' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><\/div><\/div>\n        <div class='gform_page_footer top_label'><input type='submit' id='gform_previous_button_1' class='gform_previous_button button' value='Previous'  onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  jQuery(\"#gform_1\").trigger(\"submit\",[true]); }' \/> <input type='submit' id='gform_submit_button_1' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  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                   <\/form>\n                        <\/div>\n                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_1' id='gform_ajax_frame_1' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'><\/iframe>\n                <script>\ngform.initializeOnLoaded( function() {gformInitSpinner( 1, 'https:\/\/testv81.demowebsitelinks.com\/PEMFV2\/wp-content\/plugins\/gravityforms\/images\/spinner.svg' );jQuery('#gform_ajax_frame_1').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_1');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_1').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = 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