New Patients New Patients – Please fill out the form below prior to your visit. New Patient Info First and Last Name Date of Birth (month/date/year) Address, City, State, Zip Phone Number Emergency Contact (name, relationship, phone number)Allergies to Medications? (please explain)Pregnant or Breastfeeding?YesNoWould you like to recieve our monthly newsletter?YesNoEmail Address Who 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. Δ
