Cupertino Medical Laser Center - See if I'm a candidate

1

Are you familiar with the SmartLipo procedure?* This field is required.

Yes

I’m somewhat familiar

No

2

Do you have localized areas of fat that are resistant to diet and exercise, such as love handles, saddlebags, or a double chin?* This field is required.

YESNO

3

Are you at or near your ideal body weight?* This field is required.

YESNO

4

What is your height?* This field is required.

5

What is your current weight?* This field is required.

6

Do you have conditions like diabetes or autoimmune disorder?* This field is required.

YESNO

7

Do you smoke?* This field is required.

YESNO

8

If you smoke, how many cigarettes a day do you smoke?* This field is required.

9

Are you taking any medications?* This field is required.

YESNO

10

Are you prepared to make lifestyle changes, such as maintaining a healthy diet and exercise routine, to maintain the results of the SmartLipo procedure?* This field is required.

Yes, I am

No, I’m not

11

Are you financially prepared to pay for a SmartLipo procedure? (Minimum of $5,000)* This field is required.

Yes

No, but I'm interested in other alternatives like CoolSculpting

No, but I would like to know your financing options

No

12

How did you find out about this special?* This field is required.

Facebook Ads

Google Ads

13

Full Name* This field is required.

First Name

Last Name

14

Email Address* This field is required.

example@example.com

15

Phone Number* This field is required.

16

What's the best day for us to call you?* This field is required.

17

What time of day is best for us to call?* This field is required.

18

What's the best way for us to get in touch?* This field is required.

Phone call

Text message