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52 S. Main St. | Fairfield IA. 52556

(641) 472-6274 |

30-Minute Ayurvedic Skincare Consultation

Ayurvedic Consultant: Rebecca Lansky,

Licensed Esthetician, Ayurvedic Wellness Coach

Thanks for booking your Ayurvedic Wellness Check-In. I look forward to connecting with you and learning about your wellness goals. To ensure you get the most out of your session, kindly fill out and submit this form at least XX before your appointment.

Client Questionnaire

* Required


Skincare Goals

Skincare Regimen

Nutrition & Lifestyle

Skin Type

See You Soon

Thanks so much for sharing a bit about yourself. I look forward to helping you on your wellness journey.