RejuveMedSpa

CONSULTATION

Thank you for your interest in Rejuve Med-Spa. To set up your next appointment, please submit the following form. A representative will contact you soon.

Client Information

Existing Client

New Client

Salutation:

Mr.

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Ms.

* Full Name:

Contact Information

* Phone:

- - xxx-xxx-xxxx

* E-mail:

* Please confirm
appointment by:

	Phone
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Appointment Information

Appointment Type:

	Consultation
	Treatment
	Consultation & Treatment
	Follow-Up

Reason for appointment:
(Check all that apply)

	Botox / Dermal Filler
	Chemical Peel
	Eyelid Lift (Blepharoplasty)
	Facial
	Fraxel (Skin Resurfacing)
	Hair Service
	Laser Hair Removal
	Laser Lipo
	Microdermabrasion
	Photo Facial

Appointment Needed:

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Please select date :

Time:

Questions or further info:

How did you first hear
about us?

REJUVE MED-SPA WILL ALWAYS RESPOND TO YOUR APPOINTMENT REQUEST BY THE END OF THE NEXT BUSINESS DAY. IF YOU DO NOT RECEIVE A RESPONSE, IT IS BECAUSE WE HAVE NOT RECEIVED YOUR REQUEST FOR SOME REASON. SHOULD THIS OCCUR, PLEASE EMAIL US AT HIDDENBEAUTY@REJUVEMEDSPA.COM OR CALL US AT (972) 392-7920, AND WE WILL RESPOND PROMPTLY. THANK-YOU!

Village on the Parkway 5100 Belt Line Road, Suite 816 Addison,
TX 75240 Ph.(972) 392-7920 email.hiddenbeauty@rejuvemedspa.com