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Request For Nutrition Consultation

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. The nutrition department appointment secretary will contact you by phone to schedule an appointment and discuss your personal nutrition needs/concerns.

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 (if it applies to you):      
Have you had a nutrition consultation before?   
Preferred date for consultation:
Are you interested in the Cooper Lean weight-loss program?   
 
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: