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Get in Touch

 

Rejuvenate with Nousha • NYC

630 Park Avenue

NY, NY, 10065

607.341.2280

appointments@rejuvenatewithnousha.com

 

 

Rejuvenate with Nousha • LA

Cure Spa 

22741 Pacific Coast Highway

Malibu, CA 90265

607.341.2280

appointments@rejuvenatewithnousha.com

*Now accepting appointments for in home visits 


INTAKE FORM

To speed up your experience, please fill out our Intake Form before your consultation.

Name *
Name
Home Address *
Home Address
Mobile *
Mobile
Home Phone *
Home Phone
List any serious illnesses present or past
List any allergies to medicine or skin allergies
List any medications that you take (Include Homeopathic and Herbal) - Please include the dosage, frequency, and purpose of your medication
Please list any procedures you've had done, and when they occurred



BEFORE PHOTO

To ensure best results, please take a photo of your face and email it to us before your consultation.

 

 

MEDICATIONS TO AVOID

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