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Congratulations on Your CoolSculpting Results!
We'd love to send you a FREE "I Am Beautiful" T-Shirt!
Account must be paid in full.
Limit 1 per customer.
See Terms & Conditions
Clinic
*
Amarillo
Lubbock
Staff Name
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Client First Name
*
Client Last Name
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Street Address
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City
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State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
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New Hampshire
New Jersey
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New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Phone Number
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Email Address
*
Gender
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Male
Female
T Shirt Size
*
Small
Medium
Large
X-Large
I don't need one/Received one already
CoolSculpting Area(s)
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🛈
+
-
What do you love most about being
your treatment?
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I feel beautiful
More Confidence
Results - it works!
Little or no pain
Convenience
Other
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Rate your experience
1
2
3
4
5
Tell us about your Coolsculpting Journey
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Wish List
what other areas next?
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Abdomen
Flanks
Bra Fat
Muffin Top
Inner Thighs
Outer Thighs
Banana Roll
Other
Other
Refer A Friend
Name
*
Phone
*
Email
*
Marketing Consent
:
I give American Laser Med Spa permission to use the information provided on this form and the
photographs taken today for marketing purposes
*
Yes
No
Notes (if any)
Please leave us a review! Thank you for your support!