Which location is this for? *

The Upper Level Spa (Bay Park/Clairemont)

The Upper Level Spa at Joel C Ma Studio (La Jolla)

Name *

First Name

Last Name

Your Birthday

MM

DD

YYYY

Are there any medical conditions that we should know about to help maximize your treatments?

Check All That Apply

Diabetes

Cancer / skin Cancer

Hysterectomy

Varicose Veins

Eczema

High Blood Pressure

Herpes

Excessive Moles

Heart Problems

Warts

Stomach Ulcers

Hormone Imbalance

Dermal Abrasions

Epilepsy

Poor Circulation

Dermatitis

Have you ever had or do you currently have any of the following treatments?

Check All That Apply

Collagen injections

Waxing

Chemical Peels

Microdermabrasion

Sugaring

X-Rays Recently

Dermablade

Restalane

Tanning Bed Exposure

Laser Resurfacing

Botox

Cosmetic Surgery

Are you currently having facial or massages?

Check All That Apply

Facials

Massages

Have you had a chemical peel within the last 14 days?

Yes

No

Have you had laser hair removal or electrolysis on your face?

Check all that apply

Laser Hair Removal

Electrolysis

Do you have any allergies?

Yes

No

Do you have a tendency towards redness, rashes or hives?

Yes

No

How do you consider your skin?

Sensitive

Resilient

Not Sure

Do you exercise regularly?

Yes

No

Are you under a lot of stress?

Yes

No

Do you Smoke?

Yes

No

Are you pregnant?

Yes

No

Do you wear contacts?

Yes

No

Do you have any metal implants?

Yes

No

Are you claustrophobic

Yes

No