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

Mole, Skin Tag, Wart, Age Spot Removal Consent Form

To the CLIENT: You have a right to be informed about your condition and its treatment, so that you may decide whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give, or withhold, your consent for treatment.

  • I have been informed, to my satisfaction, regarding the nature of the procedure and acknowledge that this procedure is entirely a cosmetic procedure. I acknowledge that I have been medically cleared by my private doctor concerning this procedure and have previously addressed any concerning moles, skin tag, wart, and age spot on my skin.
  • I have been informed, to my satisfaction, regarding the risks inherent to the performance of this procedure such as loss of blood, infection, reaction to anesthesia and the formation of thick or otherwise objectionable scars, thinning of the skin, discoloration, atrophy and recurrence of the lesion/mole. Should any type of skin infection occur, additional treatments or medical antibiotics may be necessary from my private doctor.
  • I understand that medical care requires my cooperation, and I will follow all post care instructions. The nature and purpose of the treatment have been explained to me. I have read and understand this agreement. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. Alternative methods of treatment and their risks and benefits have been explained to me and I understand that I have the right to refuse treatment.

Do you have or have you ever had any of the following conditions:

Are you currently taking aspirin, ibuprofen, blood thinner OR COUMADIN?

If you are taking any other blood thinner medicine, please mention prior to your treatment.


THE UNDERSIGNED acknowledges that TECHNICIAN has explained the nature of all the above noted treatment of Moles, Skin Tag, Wart and Age Spot 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.)