Please answer the following questions so that we may have a better understanding of your general lifestyle to better assist your wants and needs.

Which location is this for? *
Name *
Your Birthday
Your Birthday
Are there any medical conditions that we should know about to help maximize your treatments?
Check All That Apply
Have you ever had or do you currently have any of the following treatments?
Check All That Apply
Are you currently having facial or massages?
Check All That Apply
Have you had a chemical peel within the last 14 days?
Have you had laser hair removal or electrolysis on your face?
Check all that apply
Do you have any allergies?
Do you have a tendency towards redness, rashes or hives?
How do you consider your skin?
Do you exercise regularly?
Are you under a lot of stress?
Do you Smoke?
Are you pregnant?
Do you wear contacts?
Do you have any metal implants?
Are you claustrophobic
*The information that I’ve provided is true and accurate to the best of my knowledge. I will inform my therapist if any of my information changes in future visits to The Upper Level Spa. I understand that reactions may occur when receiving any treatment from any service provider. I Release The Upper Level Spa and all contracted employees from any liability if anything should happen while visiting the establishment, or post reactions following my visit.*