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

Ultherapy Consent Form

  • Ultherapy is a non-surgical treatment that uses Ultrasound technology to lift and tighten skin.
  • I understand that results vary from patient to patient, and occasionally, the collagen building on the inside that helps counter the effects of gravity does not have a visible effect on the outside.
  • I understand that, following the procedure, the results will unfold over a period of 60-90 days and beyond, and that some patients may benefit from more than one treatment.
  • I understand that Ultherapy is a non-invasive treatment and is not intended to produce the same results as an invasive surgical procedure .
  • I understand that no guarantees can be made as to the results of this procedure and there is a low risk that I may not see results at all.
  • I understand there can be discomfort during the treatment when the ultrasound is being delivered. I have discussed options to optimize comfort during the procedure.
  • I understand that immediately following the Ultherapy procedure, the skin may appear red for a few hours, and that it is not uncommon to experience slight swelling for a few days following treatment.
  • I understand that it is not uncommon to experience a tingling or tenderness to the touch for days to weeks following the procedure, but these are usually mild and temporary in nature.
  • Occasional temporary effects may include bruising or welts, which usually resolve in hours to days, or numbness in a select area, which usually resolves in days to weeks.
  • I understand that as with any medical procedure, there are possible risks associated with this treatment, and even if there is a low risk , these risks may include: risk of a burn that may or may not lead to scarring, temporary nerve inflammation, temporary local muscle weakness due to inflammation of nerves, and temporary numbness due to inflammation of a sensory nerve.
  • I understand that if I have had dermal filler within the past 3 months or neurotoxin, (Botox, Dysport), within the past 2 weeks, it is possible the heat from Ultherapy can break down and diminish the effectiveness of the dermal filler or neurotoxin.
  • I have had the Ultherapy procedure explained to me, I understand the risks associated with the procedure and have discussed alternative treatments that are available.

I have read and understand the information and instructions of Ultherapy. I feel I have been adequately informed of the risks of Ultherapy as well as alternate methods of treatment. All my questions have been addressed and answered to my satisfaction. I agree to the terms of this agreement. I hereby consent to an Ultherapy treatment, performed by Cosmo Med Spa & Salon Staff.


THE UNDERSIGNED acknowledges that TECHNICIAN has explained the nature of all the above noted treatment of Ultherapy 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)