{"id":6,"date":"2021-07-30T00:30:31","date_gmt":"2021-07-30T00:30:31","guid":{"rendered":"https:\/\/doctor-bio.westdermatology.com\/?page_id=6"},"modified":"2021-07-30T01:57:30","modified_gmt":"2021-07-30T01:57:30","slug":"onboarding-intake","status":"publish","type":"page","link":"https:\/\/doctor-bio.westdermatology.com\/","title":{"rendered":"Onboarding Intake"},"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_gecko gform_wrapper gravity-theme' id='gform_wrapper_1' ><div id='gf_1' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <span class='gform_description'>Welcome to the West Dermatology Family of Dermatology Practices!\r\nWhether you are coming to work at a West clinic, or one of our many partners, we want to welcome you to the family. To get to know you a little better, we have is a list of questions we&#8217;d like for you to answer as thoroughly as possible. This information will help us write a Provider bio to help promote you in the community.\r\n\r\nThe following form has multiple company uses.  From the website, to announcements that you have joined the company, to online search and reputation management. Please make sure to scroll to the bottom to make sure you answer all the questions.<\/span>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F6#gf_1' novalidate>\n        <div id='gf_progressbar_wrapper_1' class='gf_progressbar_wrapper'>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>3<\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_33' style='width:33%;'><span>33%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform_body 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'><div id=\"field_1_41\" class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><h1>Bio Card Info<\/h1><\/div><div id=\"field_1_12\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_1_12' >Why did you choose medicine as your professional field?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_12' id='input_1_12' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_11\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_1_11' >And specifically, how did you get to dermatology?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_11' id='input_1_11' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_10\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_1_10' >What interested you about West Dermatology \/ English Dermatology?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_10' id='input_1_10' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_9\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_1_9' >Why is healthy skin your passion?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_9' id='input_1_9' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_6\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_1_6' >What is your patient care philosophy? (This will be your quote)<\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_1_6' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_8\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_1_8' >Is there a specific ah-ha moment \/ or patient story that continues to verify why you got into dermatology?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_8' id='input_1_8' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_13\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_1_13' >Any advice you wish people would follow to maintain skin health?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_13' id='input_1_13' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_14\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_1_14' >What makes for a good patient doctor relationship?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_14' id='input_1_14' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_15\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_1_15' >How does your environment \/ nutrition impact skin health (in your opinion)?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_15' id='input_1_15' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_16\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_1_16' >What are some of your hobbies \/ volunteer activities?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_16' id='input_1_16' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_17\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_1_17' >What would you like to say about your family?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_17' id='input_1_17' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_18\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_1_18' >If you would like to please provide us your social media handles (LinkedIn, Facebook, Instagram, etc.).<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_18' id='input_1_18' class='textarea large'      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_next_button_1_19' class='gform_next_button button' value='Next'  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]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_2' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_2' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_1_42\" class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><h1>Website Content<\/h1><\/div><fieldset id=\"field_1_20\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Specialties (Yes\/No)<\/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='Brachytherapy'  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'>Brachytherapy<\/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='Cosmetic Dermatology'  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'>Cosmetic Dermatology<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_20_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.3' type='checkbox'  value='Dermatoimmunology'  id='choice_1_20_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_20_3' id='label_1_20_3'>Dermatoimmunology<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_20_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.4' type='checkbox'  value='Medical Dermatology'  id='choice_1_20_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_20_4' id='label_1_20_4'>Medical Dermatology<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_20_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.5' type='checkbox'  value='Radiation Oncologist'  id='choice_1_20_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_20_5' id='label_1_20_5'>Radiation Oncologist<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_20_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.6' type='checkbox'  value='Surgical Dermatology'  id='choice_1_20_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_20_6' id='label_1_20_6'>Surgical Dermatology<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_21\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_1_21' >Languages Spoken<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_21' id='input_1_21' class='textarea large'  aria-describedby=\"gfield_description_1_21\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_1_21'>(Other than English. Comfortable speaking with patients)<\/div><\/div><div id=\"field_1_22\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_1_22' >NPI #<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_1_22' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_23\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_1_23' >Practicing Dermatology since (list year &#8211; after residency)<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_1_23' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_24\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_1_24' >Biography\/Description (This is what patients will read about you on the website. Similar to the bio-card, but has more detail. See website for examples)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_24' id='input_1_24' class='textarea large'  aria-describedby=\"gfield_description_1_24\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_1_24'><a href='https:\/\/www.westdermatology.com\/providers\/brook-brouha' target=\"_blank\">Click Here for example<\/a><\/div><\/div><div id=\"field_1_25\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_1_25' >Board Certified (list all certifications)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_25' id='input_1_25' class='textarea large'  aria-describedby=\"gfield_description_1_25\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_1_25'>And if not certified yet, when will this happen?<\/div><\/div><div id=\"field_1_26\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_1_26' >Undergraduate (list all undergraduate studies along with year)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_26' id='input_1_26' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_27\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_1_27' >Graduate (list all graduate work)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_27' id='input_1_27' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_28\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_1_28' >Medical \/ PA \/ NP Education<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_28' id='input_1_28' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_29\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_1_29' >Residency<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_29' id='input_1_29' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_30\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_1_30' >Military Service<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_30' id='input_1_30' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_31\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_1_31' >Board Certified (list all)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_31' id='input_1_31' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_32\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_1_32' >Fellowship<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_32' id='input_1_32' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_33\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_1_33' >Professional Organizations<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_33' id='input_1_33' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_34\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_1_34' >Awards<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_34' id='input_1_34' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_35\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_1_35' >Provider Quote (this is listed on the website under your name, patient-focused quote on what the most important aspect of patient experience is to you)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_35' id='input_1_35' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_1_36\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Do you have a headshot?  (We can set this up for if you don&#039;t or its very old. See website for examples of headshots)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_36'><div class='gchoice gchoice_1_36_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.1' type='checkbox'  value='Yes'  id='choice_1_36_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_36_1' id='label_1_36_1'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_36_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.2' type='checkbox'  value='No'  id='choice_1_36_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_36_2' id='label_1_36_2'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_37' 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_37' 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'><div id=\"field_1_43\" class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><h1>Services<\/h1><\/div><fieldset id=\"field_1_38\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Please check all the services that you are trained in, or are getting trained for. If something is not listed, please list at the bottom of this form in the designated area. Thank you<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_1_38'><div class='gchoice gchoice_1_38_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.1' type='checkbox'  value='Acne'  id='choice_1_38_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_1' id='label_1_38_1'>Acne<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.2' type='checkbox'  value='Actinic Keratoses'  id='choice_1_38_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_2' id='label_1_38_2'>Actinic Keratoses<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.3' type='checkbox'  value='Aging \/ Sun Damaged Skin'  id='choice_1_38_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_3' id='label_1_38_3'>Aging \/ Sun Damaged Skin<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.4' type='checkbox'  value='Allergies'  id='choice_1_38_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_4' id='label_1_38_4'>Allergies<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.5' type='checkbox'  value='Alopecia Areata'  id='choice_1_38_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_5' id='label_1_38_5'>Alopecia Areata<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.6' type='checkbox'  value='Athlete&#039;s Foot'  id='choice_1_38_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_6' id='label_1_38_6'>Athlete&#8217;s Foot<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.7' type='checkbox'  value='Basal Cell Carcinoma'  id='choice_1_38_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_7' id='label_1_38_7'>Basal Cell Carcinoma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.8' type='checkbox'  value='Botox'  id='choice_1_38_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_8' id='label_1_38_8'>Botox<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.9' type='checkbox'  value='Brachytherapy'  id='choice_1_38_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_9' id='label_1_38_9'>Brachytherapy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.11' type='checkbox'  value='Brown Age Spots (Sunspots)'  id='choice_1_38_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_11' id='label_1_38_11'>Brown Age Spots (Sunspots)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.12' type='checkbox'  value='Bullous Pemphigoid'  id='choice_1_38_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_12' id='label_1_38_12'>Bullous Pemphigoid<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.13' type='checkbox'  value='Calluses and Corns'  id='choice_1_38_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_13' id='label_1_38_13'>Calluses and Corns<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.14' type='checkbox'  value='Cellulitis'  id='choice_1_38_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_14' id='label_1_38_14'>Cellulitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.15' type='checkbox'  value='Chemical Peel'  id='choice_1_38_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_15' id='label_1_38_15'>Chemical Peel<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.16' type='checkbox'  value='Clear + Brilliant'  id='choice_1_38_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_16' id='label_1_38_16'>Clear + Brilliant<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.17' type='checkbox'  value='CoolSculpting'  id='choice_1_38_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_17' id='label_1_38_17'>CoolSculpting<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.18' type='checkbox'  value='Cysts'  id='choice_1_38_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_18' id='label_1_38_18'>Cysts<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.19' type='checkbox'  value='Dermal Fillers'  id='choice_1_38_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_19' id='label_1_38_19'>Dermal Fillers<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.21' type='checkbox'  value='Dry Skin'  id='choice_1_38_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_21' id='label_1_38_21'>Dry Skin<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.22' type='checkbox'  value='Eczema\/ Atopic Dermatitis'  id='choice_1_38_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_22' id='label_1_38_22'>Eczema\/ Atopic Dermatitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.23' type='checkbox'  value='Excessive Perspiration'  id='choice_1_38_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_23' id='label_1_38_23'>Excessive Perspiration<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.24' type='checkbox'  value='Facials'  id='choice_1_38_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_24' id='label_1_38_24'>Facials<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.25' type='checkbox'  value='Fat Reduction'  id='choice_1_38_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_25' id='label_1_38_25'>Fat Reduction<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.26' type='checkbox'  value='Feminine Rejuvenation'  id='choice_1_38_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_26' id='label_1_38_26'>Feminine Rejuvenation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.27' type='checkbox'  value='Fungal Infections of the Skin'  id='choice_1_38_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_27' id='label_1_38_27'>Fungal Infections of the Skin<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.28' type='checkbox'  value='General Skin Care'  id='choice_1_38_28'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_28' id='label_1_38_28'>General Skin Care<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_29'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.29' type='checkbox'  value='Hair Loss'  id='choice_1_38_29'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_29' id='label_1_38_29'>Hair Loss<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_31'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.31' type='checkbox'  value='Hand Rejuvenation'  id='choice_1_38_31'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_31' id='label_1_38_31'>Hand Rejuvenation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_32'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.32' type='checkbox'  value='Hives'  id='choice_1_38_32'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_32' id='label_1_38_32'>Hives<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_33'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.33' type='checkbox'  value='HydraFacial'  id='choice_1_38_33'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_33' id='label_1_38_33'>HydraFacial<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_34'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.34' type='checkbox'  value='Impetigo'  id='choice_1_38_34'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_34' id='label_1_38_34'>Impetigo<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_35'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.35' type='checkbox'  value='Ingrown Hairs \/ Folliculitis'  id='choice_1_38_35'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_35' id='label_1_38_35'>Ingrown Hairs \/ Folliculitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_36'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.36' type='checkbox'  value='IPL Photofacial'  id='choice_1_38_36'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_36' id='label_1_38_36'>IPL Photofacial<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_37'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.37' type='checkbox'  value='Isolaz Laser'  id='choice_1_38_37'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_37' id='label_1_38_37'>Isolaz Laser<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_38'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.38' type='checkbox'  value='Keloid (Scars)'  id='choice_1_38_38'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_38' id='label_1_38_38'>Keloid (Scars)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_39'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.39' type='checkbox'  value='Keratosis Pilaris'  id='choice_1_38_39'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_39' id='label_1_38_39'>Keratosis Pilaris<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_41'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.41' type='checkbox'  value='Kybella'  id='choice_1_38_41'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_41' id='label_1_38_41'>Kybella<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_42'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.42' type='checkbox'  value='Laser Hair Removal'  id='choice_1_38_42'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_42' id='label_1_38_42'>Laser Hair Removal<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_43'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.43' type='checkbox'  value='Laser Skin Resurfacing'  id='choice_1_38_43'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_43' id='label_1_38_43'>Laser Skin Resurfacing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_44'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.44' type='checkbox'  value='Lentigo (Age Spots)'  id='choice_1_38_44'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_44' id='label_1_38_44'>Lentigo (Age Spots)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_45'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.45' type='checkbox'  value='Lichen Planus'  id='choice_1_38_45'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_45' id='label_1_38_45'>Lichen Planus<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_46'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.46' type='checkbox'  value='Lumps, Bumps, and Moles'  id='choice_1_38_46'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_46' id='label_1_38_46'>Lumps, Bumps, and Moles<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_47'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.47' type='checkbox'  value='Lupus'  id='choice_1_38_47'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_47' id='label_1_38_47'>Lupus<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_48'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.48' type='checkbox'  value='Melanoma'  id='choice_1_38_48'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_48' id='label_1_38_48'>Melanoma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_49'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.49' type='checkbox'  value='Melasma'  id='choice_1_38_49'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_49' id='label_1_38_49'>Melasma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_51'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.51' type='checkbox'  value='Microdermabrasion'  id='choice_1_38_51'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_51' id='label_1_38_51'>Microdermabrasion<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_52'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.52' type='checkbox'  value='Microneedling'  id='choice_1_38_52'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_52' id='label_1_38_52'>Microneedling<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_53'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.53' type='checkbox'  value='Mohs Micrographic Surgery'  id='choice_1_38_53'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_53' id='label_1_38_53'>Mohs Micrographic Surgery<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_54'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.54' type='checkbox'  value='Mole Removal'  id='choice_1_38_54'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_54' id='label_1_38_54'>Mole Removal<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_55'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.55' type='checkbox'  value='Molluscum Contagiosum'  id='choice_1_38_55'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_55' id='label_1_38_55'>Molluscum Contagiosum<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_56'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.56' type='checkbox'  value='Nail Disorders'  id='choice_1_38_56'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_56' id='label_1_38_56'>Nail Disorders<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_57'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.57' type='checkbox'  value='Nail Health'  id='choice_1_38_57'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_57' id='label_1_38_57'>Nail Health<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_58'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.58' type='checkbox'  value='Pellev\u00e9'  id='choice_1_38_58'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_58' id='label_1_38_58'>Pellev\u00e9<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_59'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.59' type='checkbox'  value='Photodynamic Therapy (PDT)'  id='choice_1_38_59'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_59' id='label_1_38_59'>Photodynamic Therapy (PDT)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_61'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.61' type='checkbox'  value='PicoWay Laser'  id='choice_1_38_61'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_61' id='label_1_38_61'>PicoWay Laser<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_62'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.62' type='checkbox'  value='PinPointe Laser'  id='choice_1_38_62'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_62' id='label_1_38_62'>PinPointe Laser<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_63'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.63' type='checkbox'  value='Pityriasis Rosea'  id='choice_1_38_63'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_63' id='label_1_38_63'>Pityriasis Rosea<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_64'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.64' type='checkbox'  value='Platelet-Rich Plasma (PRP)'  id='choice_1_38_64'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_64' id='label_1_38_64'>Platelet-Rich Plasma 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value='Rosacea'  id='choice_1_38_68'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_68' id='label_1_38_68'>Rosacea<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_69'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.69' type='checkbox'  value='Scabies'  id='choice_1_38_69'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_69' id='label_1_38_69'>Scabies<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_71'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.71' type='checkbox'  value='Scleroderma'  id='choice_1_38_71'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_71' id='label_1_38_71'>Scleroderma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_72'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.72' type='checkbox'  value='Seborrheic Keratosis'  id='choice_1_38_72'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_72' id='label_1_38_72'>Seborrheic Keratosis<\/label>\n\t\t\t\t\t\t\t<\/div><div 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