11550 Jonesbridge Rd, Suite# 6, Alpharetta GA 30022
Email: info@cosmomedspaatl.com         Tel: (678) 829-7722

Mesotherapy Consent Form

Mesotherapy is an injection technique with a broad range of applications. Mesotherapy involves the injection of customized therapeutic substance base on client needs placed just Mesotherapy is used for cosmetic purposes such as spot fat reduction, cellulite removal, face and neck rejuvenation, hair loss, and alopecia.

I have been informed of the possible risks and side effects of mesotherapy including but not limited, bruising, irritation, discomfort, and bleeding at the site. Rare but reported risks include infection and allergic reaction manifested as redness, swelling, and discomfort at the injected sites.

  • I understand the nature of the proposed procedure and the risks and damages have been explained to me.
  • I understand that there have been no warranties, assurances, or guarantees of successful treatment made to me.
  • I desire to undergo this treatment after having considered the information contained in this document, the information provided to me through materials provided to me and educate me about the treatment.
  • I understand that the treatment is most successful when combined with following after care instructions.

Post-Treatment Instructions

  • Avoid significant movement or massage of the treated area.
  • Avoid strenuous exercise for 24 hours.
  • Avoid extensive sun or heat for 72 hours.
  • Avoid consuming excess amounts of alcohol or salts to avoid excess swelling.
  • If you have swelling you may apply a cool compress for 15 minutes each hour.

I acknowledge that I have had the opportunity to ask any questions of my physician with respect to the proposed therapy and the procedures to be utilized and all my questions have been answered to my full satisfaction.

My signature on this agreement will constitute a full and final release of any legal responsibility resulting from the administration of mesotherapy in my case, and/or any other medical treatment that may be necessary as a result thereof. To my knowledge, I am not pregnant at this time and will notify.


THE UNDERSIGNED acknowledges that TECHNICIAN has explained the nature of all the above noted treatment of Masotherapy procedures including the risks and dangers inherent therein.

I HEREBY CONSENT to performing the above-noted treatment procedures on me and in consideration of their so doing; I hereby release and forever discharge Cosmo Med Spa & Salon, from all claims, demands, damages, actions or causes of action arising out of the performance of the said treatment procedures, which I, my heirs, executors, administrators or assigns can, shall, or may have. (NO REFUND ON ANY TREATMENT)