My diet and exercise efforts aren’t giving me my desired results.  Yes No

I would like to feel more confident about the appearance of my body. Yes No

I would prefer a fat reduction treatment that does not involve surgery.  Yes No

I would feel better about my appearance if I eliminate fat in one or more of the following
areas. Check all that apply.  Abdomen Flanks(love handles/muffin tops) Bra fat Back fat Banana roll(area under buttocks) Outer thighs Inner thighs Submental(double chin) Upper arms

I’m excited to know more about a fat reduction treatment that is non-invasive, safe,
lasting and clinically proven.  Yes No

First Name:
Last Name:
Email:
Phone Number: