New Patients New Patients – Please fill out the form below prior to your visit.New Patient Info First and Last NameDate of Birth (month/date/year)Address, City, State, ZipPhone NumberEmergency Contact (name, relationship, phone number)Allergies to Medications? (please explain)Pregnant or Breastfeeding?YesNoWould you like to recieve our monthly newsletter?YesNoEmail AddressWho referred you to us?I understand that there is a 4 hour cancellation policy for all procedures and appointmentsYesNoPlease note, this excludes CoolSculpting appointments as we require 24 hours notice for cancellation due to the length of these appointments. A missed appointment fee is $75.
