{"id":18,"date":"2019-11-25T09:30:51","date_gmt":"2019-11-24T22:30:51","guid":{"rendered":"https:\/\/www.maxxbymakayla.com\/?page_id=18"},"modified":"2019-12-16T12:55:41","modified_gmt":"2019-12-16T01:55:41","slug":"consultations","status":"publish","type":"page","link":"https:\/\/www.maxxbymakayla.com\/consultations\/","title":{"rendered":"Consultations"},"content":{"rendered":"<script type=\"text\/javascript\">var 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#112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><div id='gf_2' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_2' id='gform_2' class='client-form' action='\/wp-json\/wp\/v2\/pages\/18#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'><\/span><\/div><div id='gf_step_2_2' class='gf_step gf_step_next gf_step_pending'><span class='gf_step_number'>2<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_2_3' class='gf_step gf_step_last gf_step_pending'><span class='gf_step_number'>3<\/span><span class='gf_step_label'><\/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'><ul id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_2_8\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_8\" ><p style=\"text-align:center;\">This consultation form will assist your therapist in evaluating your needs and choosing the correct treatment\/plan to reach your goals.<\/p>\n\n<p style=\"text-align:center;\">All information is strictly confidential &#038; remains the property of House of Maxx.<\/p><\/li><li id=\"field_2_2\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_2\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_2_2'>\n                            \n                            <span id='input_2_2_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.3' id='input_2_2_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_2_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_2_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.6' id='input_2_2_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_2_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_2_4\" class=\"gfield gfield--type-date gfield--input-type-datedropdown gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_4\" ><label class='gfield_label gform-field-label' >Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_2_4' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_2_4_2_container'><select name='input_4[]' id='input_2_4_2'   aria-required='true'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_2_4_1_container'><select name='input_4[]' id='input_2_4_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_2_4_3_container'><select name='input_4[]' id='input_2_4_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_2_3\" class=\"gfield gfield--type-phone gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_3\" ><label class='gfield_label gform-field-label' for='input_2_3'>Contact Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/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><\/li><li id=\"field_2_5\" class=\"gfield gfield--type-email gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_5\" ><label class='gfield_label gform-field-label' for='input_2_5'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_2_5' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_2_27\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_27\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_2_27' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_2_27_1_container' >\n                                        <input type='text' name='input_27.1' id='input_2_27_1' value=''    aria-required='true'    \/>\n                                        <label for='input_2_27_1' id='input_2_27_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_27_3_container' >\n                                    <input type='text' name='input_27.3' id='input_2_27_3' value=''    aria-required='true'    \/>\n                                    <label for='input_2_27_3' id='input_2_27_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_27_4_container' >\n                                        <input type='text' name='input_27.4' id='input_2_27_4' value=''      aria-required='true'    \/>\n                                        <label for='input_2_27_4' id='input_2_27_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_27_5_container' >\n                                    <input type='text' name='input_27.5' id='input_2_27_5' value=''    aria-required='true'    \/>\n                                    <label for='input_2_27_5' id='input_2_27_5_label' class='gform-field-label gform-field-label--type-sub '>Post Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_2_27_6_container' >\n                                        <select name='input_27.6' id='input_2_27_6'   aria-required='true'    ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' selected='selected'>Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_2_27_6' id='input_2_27_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_2_6\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_6\" ><label class='gfield_label gform-field-label' for='input_2_6'>How did you hear about us?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_2_6' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_2_7' 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-7' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_2_2' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_2_9\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_3col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_9\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Please indicate any recent or current experience of the following conditions<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_9'><li class='gchoice gchoice_2_9_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.1' type='checkbox'  value='Recent injury'  id='choice_2_9_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_1' id='label_2_9_1' class='gform-field-label gform-field-label--type-inline'>Recent injury<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_9_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.2' type='checkbox'  value='Cancer\/Remission'  id='choice_2_9_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_2' id='label_2_9_2' class='gform-field-label gform-field-label--type-inline'>Cancer\/Remission<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_9_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.3' type='checkbox'  value='Circulatory\/Lymphatic Dysfunction'  id='choice_2_9_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_3' id='label_2_9_3' class='gform-field-label gform-field-label--type-inline'>Circulatory\/Lymphatic Dysfunction<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_9_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.4' type='checkbox'  value='Numbness\/Tingling'  id='choice_2_9_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_4' id='label_2_9_4' class='gform-field-label gform-field-label--type-inline'>Numbness\/Tingling<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_9_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.5' type='checkbox'  value='High\/Low Blood pressure'  id='choice_2_9_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_5' id='label_2_9_5' class='gform-field-label gform-field-label--type-inline'>High\/Low Blood pressure<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_9_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.6' type='checkbox'  value='Thyroid Condition'  id='choice_2_9_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_6' id='label_2_9_6' class='gform-field-label gform-field-label--type-inline'>Thyroid Condition<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_9_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.7' type='checkbox'  value='Menopause'  id='choice_2_9_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_7' id='label_2_9_7' class='gform-field-label gform-field-label--type-inline'>Menopause<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_9_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.8' type='checkbox'  value='Claustrophobia'  id='choice_2_9_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_8' id='label_2_9_8' class='gform-field-label gform-field-label--type-inline'>Claustrophobia<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_9_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.9' type='checkbox'  value='Asthma'  id='choice_2_9_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_9' id='label_2_9_9' class='gform-field-label gform-field-label--type-inline'>Asthma<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_9_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.11' type='checkbox'  value='Arthritis'  id='choice_2_9_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_11' id='label_2_9_11' class='gform-field-label gform-field-label--type-inline'>Arthritis<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_9_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.12' type='checkbox'  value='HIV'  id='choice_2_9_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_12' id='label_2_9_12' class='gform-field-label gform-field-label--type-inline'>HIV<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_9_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.13' type='checkbox'  value='Depression\/Anxiety'  id='choice_2_9_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_13' id='label_2_9_13' class='gform-field-label gform-field-label--type-inline'>Depression\/Anxiety<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_9_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.14' type='checkbox'  value='Recent Surgery'  id='choice_2_9_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_14' id='label_2_9_14' class='gform-field-label gform-field-label--type-inline'>Recent Surgery<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_9_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.15' type='checkbox'  value='Hepatitis Epilepsy'  id='choice_2_9_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_15' id='label_2_9_15' class='gform-field-label gform-field-label--type-inline'>Hepatitis Epilepsy<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_9_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.16' type='checkbox'  value='Heart Problems'  id='choice_2_9_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_16' id='label_2_9_16' class='gform-field-label gform-field-label--type-inline'>Heart Problems<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_9_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.17' type='checkbox'  value='Diabetes'  id='choice_2_9_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_17' id='label_2_9_17' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_9_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.18' type='checkbox'  value='Pregnant\/Breast Feeding'  id='choice_2_9_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_18' id='label_2_9_18' class='gform-field-label gform-field-label--type-inline'>Pregnant\/Breast Feeding<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_10\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_10\" ><label class='gfield_label gform-field-label' for='input_2_10'>Please list any health conditions or allergies your therapist should be aware of<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_2_10' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_11\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_11\" ><label class='gfield_label gform-field-label' for='input_2_11'>Please list any current health care treatment and\/or medication or supplements that you are currently taking<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_2_11' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_12\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_12\" ><label class='gfield_label gform-field-label' for='input_2_12'>Have you ever been on any form of acne treatment such as Roaccutane \/Retin-A? Please list<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_2_12' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_13\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_13\" ><label class='gfield_label gform-field-label' for='input_2_13'>What do you hope to achieve from your visit to House of Maxx?<\/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><\/li><li id=\"field_2_14\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_14\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Have you ever had<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_14'><li class='gchoice gchoice_2_14_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.1' type='checkbox'  value='Dermal Fillers\/ Botox'  id='choice_2_14_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_14_1' id='label_2_14_1' class='gform-field-label gform-field-label--type-inline'>Dermal Fillers\/ Botox<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_14_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.2' type='checkbox'  value='Chemical Peels'  id='choice_2_14_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_14_2' id='label_2_14_2' class='gform-field-label gform-field-label--type-inline'>Chemical Peels<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_14_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.3' type='checkbox'  value='Microdermabrasion'  id='choice_2_14_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_14_3' id='label_2_14_3' class='gform-field-label gform-field-label--type-inline'>Microdermabrasion<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_14_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.4' type='checkbox'  value='Laser\/IPL\/Fraxel'  id='choice_2_14_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_14_4' id='label_2_14_4' class='gform-field-label gform-field-label--type-inline'>Laser\/IPL\/Fraxel<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_21\" class=\"gfield gfield--type-list gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_21\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Dermal Fillers\/ Botox<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><style type=\"text\/css\">\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons {\n\t\t\t\t\t\t\tvertical-align: middle !important;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons img {\n\t\t\t\t\t\t\tbackground-color: transparent !important;\n\t\t\t\t\t\t\tbackground-position: 0 0;\n\t\t\t\t\t\t\tbackground-size: 16px 16px !important;\n\t\t\t\t\t\t\tbackground-repeat: no-repeat;\n\t\t\t\t\t\t\tborder: none !important;\n\t\t\t\t\t\t\twidth: 16px !important;\n\t\t\t\t\t\t\theight: 16px !important;\n\t\t\t\t\t\t\topacity: 0.5;\n\t\t\t\t\t\t\ttransition: opacity .5s ease-out;\n\t\t\t\t\t\t    -moz-transition: opacity .5s ease-out;\n\t\t\t\t\t\t    -webkit-transition: opacity .5s ease-out;\n\t\t\t\t\t\t    -o-transition: opacity .5s ease-out;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons a:hover img {\n\t\t\t\t\t\t\topacity: 1.0;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\t<\/style><div class='ginput_container ginput_container_list ginput_list'><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_21_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_21_col_2' class='gfield_list_col_even' \/><col id='gfield_list_21_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_21_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th scope=\"col\">Location of treatment<\/th><th scope=\"col\">Date of treatment<\/th><th scope=\"col\">Type of treatment<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_21_cell1' data-label='Location of treatment'><input aria-invalid='false' aria-required=\"true\"  aria-label='Location of treatment, Row 1' data-aria-label-template='Location of treatment, Row {0}' type='text' name='input_21[]' value=''   \/><\/td><td class='gfield_list_cell gfield_list_21_cell2' data-label='Date of treatment'><input aria-invalid='false' aria-required=\"true\"  aria-label='Date of treatment, Row 1' data-aria-label-template='Date of treatment, Row {0}' type='text' name='input_21[]' value=''   \/><\/td><td class='gfield_list_cell gfield_list_21_cell3' data-label='Type of treatment'><input aria-invalid='false' aria-required=\"true\"  aria-label='Type of treatment, Row 1' data-aria-label-template='Type of treatment, Row {0}' type='text' name='input_21[]' value=''   \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id=\"field_2_22\" class=\"gfield gfield--type-list gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_22\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Chemical Peels<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_list ginput_list'><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_22_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_22_col_2' class='gfield_list_col_even' \/><col id='gfield_list_22_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_22_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th scope=\"col\">Location of treatment<\/th><th scope=\"col\">Date of treatment<\/th><th scope=\"col\">Type of treatment<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_22_cell1' data-label='Location of treatment'><input aria-invalid='false' aria-required=\"true\"  aria-label='Location of treatment, Row 1' data-aria-label-template='Location of treatment, Row {0}' type='text' name='input_22[]' value=''   \/><\/td><td class='gfield_list_cell gfield_list_22_cell2' data-label='Date of treatment'><input aria-invalid='false' aria-required=\"true\"  aria-label='Date of treatment, Row 1' data-aria-label-template='Date of treatment, Row {0}' type='text' name='input_22[]' value=''   \/><\/td><td class='gfield_list_cell gfield_list_22_cell3' data-label='Type of treatment'><input aria-invalid='false' aria-required=\"true\"  aria-label='Type of treatment, Row 1' data-aria-label-template='Type of treatment, Row {0}' type='text' name='input_22[]' value=''   \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id=\"field_2_23\" class=\"gfield gfield--type-list gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_23\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Microdermabrasion<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_list ginput_list'><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_23_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_23_col_2' class='gfield_list_col_even' \/><col id='gfield_list_23_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_23_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th scope=\"col\">Location of treatment<\/th><th scope=\"col\">Date of treatment<\/th><th scope=\"col\">Type of treatment<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_23_cell1' data-label='Location of treatment'><input aria-invalid='false' aria-required=\"true\"  aria-label='Location of treatment, Row 1' data-aria-label-template='Location of treatment, Row {0}' type='text' name='input_23[]' value=''   \/><\/td><td class='gfield_list_cell gfield_list_23_cell2' data-label='Date of treatment'><input aria-invalid='false' aria-required=\"true\"  aria-label='Date of treatment, Row 1' data-aria-label-template='Date of treatment, Row {0}' type='text' name='input_23[]' value=''   \/><\/td><td class='gfield_list_cell gfield_list_23_cell3' data-label='Type of treatment'><input aria-invalid='false' aria-required=\"true\"  aria-label='Type of treatment, Row 1' data-aria-label-template='Type of treatment, Row {0}' type='text' name='input_23[]' value=''   \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id=\"field_2_24\" class=\"gfield gfield--type-list gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_24\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Laser\/IPL\/Fraxel<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_list ginput_list'><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_24_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_24_col_2' class='gfield_list_col_even' \/><col id='gfield_list_24_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_24_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th scope=\"col\">Location of treatment<\/th><th scope=\"col\">Date of treatment<\/th><th scope=\"col\">Type of treatment<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_24_cell1' data-label='Location of treatment'><input aria-invalid='false' aria-required=\"true\"  aria-label='Location of treatment, Row 1' data-aria-label-template='Location of treatment, Row {0}' type='text' name='input_24[]' value=''   \/><\/td><td class='gfield_list_cell gfield_list_24_cell2' data-label='Date of treatment'><input aria-invalid='false' aria-required=\"true\"  aria-label='Date of treatment, Row 1' data-aria-label-template='Date of treatment, Row {0}' type='text' name='input_24[]' value=''   \/><\/td><td class='gfield_list_cell gfield_list_24_cell3' data-label='Type of treatment'><input aria-invalid='false' aria-required=\"true\"  aria-label='Type of treatment, Row 1' data-aria-label-template='Type of treatment, Row {0}' type='text' name='input_24[]' value=''   \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_15' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"1\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"1\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_2_15' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_2\").val(\"3\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_2\").val(\"3\");  jQuery(\"#gform_2\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_3' class='gform_page' data-js='page-field-id-15' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_2_3' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_2_28\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_28\" ><p>We LOVE keeping in touch with our clients and always encourage you to tag or contact us if you have any questions via Instagram.<p>\n\n<p>Be sure to follow <a href=\"https:\/\/www.instagram.com\/house.of.maxx\/\" target=\"_blank\">@house.of.maxx<\/a> <a href=\"https:\/\/www.instagram.com\/hom.makayla\/\" target=\"_blank\">@hom.makayla<\/a> <a href=\"https:\/\/www.instagram.com\/hom.maxine\/\" target=\"_blank\">@hom.maxine<\/a> <a href=\"https:\/\/www.instagram.com\/hom.jenny\/\" target=\"_blank\">@hom.jenny<\/a><\/p><\/li><li id=\"field_2_17\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_17\" ><label class='gfield_label gform-field-label' >Are you okay with House of Maxx using your photos for social media?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_17'>\n\t\t\t<li class='gchoice gchoice_2_17_0'>\n\t\t\t\t<input name='input_17' type='radio' value='Yes'  id='choice_2_17_0'    \/>\n\t\t\t\t<label for='choice_2_17_0' id='label_2_17_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_17_1'>\n\t\t\t\t<input name='input_17' type='radio' value='No'  id='choice_2_17_1'    \/>\n\t\t\t\t<label for='choice_2_17_1' id='label_2_17_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_18\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_18\" ><p>PLEASE NOTE IT IS NOT ADVISED TO UNDERGO TREATMENT IF YOU ARE EXPERIENCING COLD OR FLU LIKE SYMPTOMS<\/p>\n\n<p>I 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 &#038; 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.<\/p>\n\n<p>House of Maxx takes no responsibility for lack of results in the case of client not being compliant with prescription or protocol.<\/p><\/li><li id=\"field_2_19\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_19\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_19.1' id='input_2_19_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_2_19_1' >I understand that House of Maxx has the right to charge for appointments cancelled or broken without 24 hours\u2019 notice.<span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/label><input type='hidden' name='input_19.2' value='I understand that House of Maxx has the right to charge for appointments cancelled or broken without 24 hours\u2019 notice.' class='gform_hidden' \/><input type='hidden' name='input_19.3' value='1' class='gform_hidden' \/><\/div><\/li><li id=\"field_2_20\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_20\" ><label class='gfield_label gform-field-label' for='input_2_20'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_20' id='input_2_20' type='text' value='06\/04\/2024' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_2_20_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_20_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_20' class='gform_hidden' value='https:\/\/www.maxxbymakayla.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_25\" class=\"gfield gfield--type-signature gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_25\" ><label class='gfield_label gform-field-label' for='input_2_25'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_2_25_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_2_25_valid' id='input_2_25_valid' \/><canvas id='input_2_25' width='300' height='180'><\/canvas><\/div><\/div><\/li><li id=\"field_2_26\" class=\"gfield gfield--type-captcha field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_26\" ><label class='gfield_label gform-field-label' for='input_2_26'>CAPTCHA<\/label><div id='input_2_26' class='ginput_container ginput_recaptcha' data-sitekey='6LfgR8gUAAAAACU7IkkY8JXpNO7WBCM6LHspC67i'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/li><\/ul><\/div>\n        <div class='gform_page_footer top_label'><input type='submit' id='gform_previous_button_2' 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