508  Medical  Center  Blvd  Suite  300  Conroe,  Texas  77304    www.conroefamilydoctor.com    www.conroesculpsure.com    

                                   

Trang D.Nguyen, M.D. Lourdes Orellana, P.A.

Bethany M. Manard, N.P. (936) 441-2012 office

(936) 494-4012 fax

Treatment Consultation Form

Patient Name: ______________________________________________ Date: _____________

Address: ___________________________________________________

City/State: _________________________________________________

Gender: __________ Weight: ____________ Age: ______

Phone: ________________________________

Email: _____________________________________________

What are the patient’s areas of concern? _____________________________________________ _____________________________________________________________________________________ How did he/she hear about SculpSure®? ______________________________________________ _____________________________________________________________________________________ Has your patient tried other fat loss methods? If yes, please list: _____________________________________________________________________________________ Is your patient preparing for any special events? ______________________________________ _____________________________________________________________________________________

Notes: