CoolSculpting + CoolTone Virtual Consultation Form

Name*
First Last
Email*
Phone*
Date of Birth*
Gender*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Emergency Contact Name*
First Last
Emergency Contact Phone Number*
How Did You Hear About Cool Contours?*
Have You Had CoolSculpting or CoolTone Done Before?*
Consent*
I understand the virtual consultation is NOT a complete substitute for an in-person, physical consultation and that my treatment 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.

I agree to the statements above and give my consent for the virtual consultation.