Cool Contours Virtual Consultation Form

Virtual Consultation Form

First Name

Last Name

Phone

Date Of Birth

Gender

Address

How did you hear about Cool Contours?

Have you had CoolSculpting or CoolTone done before?

Preferred location

Message

• I understand the Virtual Consultation is NOT a complete substitute for an in-person, physical consultations and assessment, and that my treat plan and package is subject to change.
• I agree to discuss details of my medical history, examinations, and tests during the consultation.
• I agree to a physical examination during the consultation
• I agree that all existing laws regarding access to medical information and copies of medical records apply to this virtual consultation.
• I agree reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with this virtual consultation, and all existing confidentiality protections under federal and VA state law apply to information disclosed during this consultation.

Book a free consultation

Fairfax: (703) 665-3281

Arlington: (703) 574-3007

Chantilly: (703) 665-3281

Virtual Consultation Form

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Fairfax Location

Arlington Location
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Chantilly Location
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