EmSculpt NEO New Patient Questionaire

First Name

Last Name

Phone *

Email *

2) What are your goals for that body part? Check all that apply.

3) Do you currently have active cancer?

Yes

4) Do you have ANY metal in your body? Examples are joint replacements, metal screws/rods, pacemaker or metal mesh stent, copper IUD, vasectomy clips, etc. Dental work does not apply.

Yes

5) If you answered NO to number 3 and 4, would you like to schedule a complimentary demonstration of the Emsculpt Neo?

Yes

How did you hear about us?

HUB Fitness

Flyer

Social Media

Other

By checking this box, I consent to receive non-marketing text messages from Phoenix Anti-Aging Clinic regarding my appointments and scheduling. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others.from Phoenix Anti-Aging Clinic at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.