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* 1. What is your gender?

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* 2. How old are you?

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* 3. What is your current weight in pounds?

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* 4. What is your current height?

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* 5. Please choose all the area you would like to target

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* 6. If you are treating the tummy area, what are the dimensions of the area with stubborn fat?

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* 7. What is bothering you?

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* 8. How thick is the stubborn fat layer when you pinch it?

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* 9. Do you have one of the followings?

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* 10. How do you describe your lifestyle?

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* 11. Have you heard about the Coolsculpting before?

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* 12. What is your budget?

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* 13. How did you hear about us?

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* 14. Please fill in your contact information to receive the $100 discount coupon

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* 15. How do you like us to contact you?

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