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Request For EBT Scan Appointment

Before sending an e-mail with your question or feedback, be sure to look at our web site for the answer to your question. The site map may help.

Due to the volume of inquiries and also ethical considerations, it is not possible to reply personally to individuals seeking specific personal fitness or medical advice. Information provided to our visitors, either on this web site or in e-mail responses, should not be construed as medical advice or used as a substitute for the expert care and advice of your physician.

This form is only a request, not a confirmed appointment. An appointment secretary will contact you by phone to schedule an appointment.

Fields marked with an asterisk (*) are required fields. Thank you.

Contact Information
* First Name:  
* Last Name:  
* E-mail Address:  
Organization/Company Name:
Address:
City:
State:
Country:
Postal Code:
Daytime Phone:
Daytime Fax:
 
Appointment Information
Please select from the following:      
Have you had an EBT scan before?   
If Yes, then on what date?
If Yes, then was it performed at Cooper Clinic?   
Preferred date for appointment:
 
How did you hear about Cooper Clinic or Cooper Aerobics Center?  
Magazine Name:
Magazine Name:
TV Show/Station:
Web Site Address:
Newspaper Name:
Newspaper Name:
Radio Station/Program:
Billboard Location:
Banner Slogan: