Intake Form

1

Your Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Your Mobile Number* This field is required.

Please enter a valid phone number.

4

Please select the package you want to buy* This field is required.

Skin & Hair Consultation Rs 299

Skin & Hair Care Programme Rs 798

PCOS, Skin & Hair Care Programme Rs 1297

5

Who are you buying it for?* This field is required.

Self

Someone else

6

Recipient Details* This field is required.Please enter the name of the person for whom you are buying the package

7

Recipient's Mobile Number* This field is required.

8

How did you hear about us?

9

Thank you

Someone from our team will reach out to you shortly to process the payment.

We will share the gift card with you & the recipent. The coupon code on the gift card can be used multiples times till the services in the packages aren't exhausted. The code will be valid for a month from the date of purchase.