Renew & Restore Wellness: Cryoslimming Intake Form

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After you fill out this request, we will contact you to go over details and availability before scheduling your first appointment. If you would like faster service and direct information please contact us at (540) 753-3837 or hello@renewandrestorewellnessva.com

Email *

Your name *

Phone number *

Preferred contact method *

Phone

Required

Are you a new or existing customer? *

I am a new customer

I am an existing customer

What is your current weight and height? *

The more we understand your goals, the better we can help. What do you want to accomplish with Cryoslimming? *

What area of your body are you looking to modify with Cryoslimming? *

Choose all that apply

Belly/love-handles

Glutes/thighs

Arms

Neck

Other:

Required

What other aspects of a healthy lifestyle do you prioritize? *

Healthy Diet

Regular exercise

Neither

Other:

Required

Questions and comments

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