Consultations1 2 3 This consultation form will assist your therapist in evaluating your needs and choosing the correct treatment/plan to reach your goals.All information is strictly confidential & remains the property of House of Maxx.Name* First Last Date of birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Contact Number*Email* How did you hear about us?* Please indicate any recent or current experience of the following conditions Recent injury Cancer/Remission Circulatory/Lymphatic Dysfunction Numbness/Tingling High/Low Blood pressure Thyroid Condition Menopause Claustrophobia Asthma Arthritis HIV Depression/Anxiety Recent Surgery Hepatitis Epilepsy Heart Problems Diabetes Pregnant/Breast FeedingPlease list any health conditions or allergies your therapist should be aware ofPlease list any current health care treatment and/or medication or supplements that you are currently takingHave you ever been on any form of acne treatment such as Roaccutane /Retin-A? Please listWhat do you hope to achieve from your visit to House of Maxx?Have you ever had Dermal Fillers/ Botox Chemical Peels Microdermabrasion Laser/IPL/FraxelDermal Fillers/ Botox*Location of treatmentDate of treatmentType of treatmentChemical Peels*Location of treatmentDate of treatmentType of treatmentMicrodermabrasion*Location of treatmentDate of treatmentType of treatmentLaser/IPL/Fraxel*Location of treatmentDate of treatmentType of treatment Are you okay with House of Maxx using your photos for social media?*YesNoPLEASE NOTE IT IS NOT ADVISED TO UNDERGO TREATMENT IF YOU ARE EXPERIENCING COLD OR FLU LIKE SYMPTOMSI confirm to the best of my knowledge that the information I have provided is correct and I have not withheld any information that may be relevant to my treatment. I certify that the preceding medical, health and skin history statements are true & correct. I understand it is my responsibility to inform my therapist of any change current medical and health conditions and to inform House of Maxx of any changes in the future as this is essential to execute correct treatment procedures.House of Maxx takes no responsibility for lack of results in the case of client not being compliant with prescription or protocol.Consent* I understand that House of Maxx has the right to charge for appointments cancelled or broken without 24 hours’ notice.*Date Date Format: DD slash MM slash YYYY Signature*CAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.