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

First Name

Last Name

Date of Birth

Age

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mobile

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Home Phone

(###)

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Email Address

Health History

List any serious illnesses present or past

Allergies

List any allergies to medicine or skin allergies

Medications

List any medications that you take (Include Homeopathic and Herbal) - Please include the dosage, frequency, and purpose of your medication

Plastic Surgery

Please list any procedures you've had done, and when they occurred

Referred By

What Procedure Are You Coming In For?

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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