Registration Form

Complete the form below to confirm your registration.
All fields are required, unless otherwise specified.

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Please fill out the required fields, marked in red below.

Email Address

First and Last Name

As you would like it to appear on your certificate

Practice Name

Medical Title

As you would like it to appear on your certificate

NPI #

Chosen Pronoun

Cell Phone Number

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Cell Phone Number

Devices Owned CoolSculpting® Legacy CoolSculpting® Elite CoolTone® Diamond Glow®

Years Performing Treatments

Personal Objective for Attending CoolSculpting University

Clothing Size Gender Top Size Size Chart Bottom Size Size Chart Specialty Size

Dietary Restrictions and Other Considerations

Terms & Conditions

Attendees must complete all sessions of CoolSculpting® University to be eligible to receive credit for attendance from Allergan Aesthetics. Travel accommodations, including ground transportation to attend CoolSculpting® University and other events are the responsibility of the Attendee. Allergan Aesthetics shall not reimburse for travel or expenses associated with the Attendee's participation at any sponsored Allergan Aesthetics event; unless otherwise agreed to in writing. Any Allergan Aesthetics scheduled after-hour activities are strictly social and voluntary. Non-registered guests are not eligible to participate in CoolSculpting® University related activities. Attendees of CoolSculpting® University shall indemnify and hold Allergan Aesthetics harmless of and from any and all liability for damages related to personal injuries or property damage that may result from or be in any way related to any Allergan Aesthetics sponsored event. Allergan Aesthetics is not responsible for any lost, stolen, or misplaced CoolSculpting® products that may be provided to Attendees during CoolSculpting® University. Allergan Aesthetics reserves the right to charge a $500 cancellation fee for any Attendee who cancels within seven (7) days before the start of the CoolSculpting® University session and Allergan Aesthetics is unable to fill his or her position.

By clicking SUBMIT, I agree to the terms and conditions listed above.