Consent To Treat

I give permission for Cocooning® / Cosima Lux to treat me.(Required)

I understand that:

  • Cocooning® will not send my medical record information to my insurance company.
  • I must pay cost of my care at rate detailed on, unless established sliding scale cost was established in writing (emailed from

I understand:

  • I have the right to refuse any procedure or treatment.
  • I have the right to discuss all medical treatments with my clinician.
  • I may allow Cosima Lux to share information with my other providers by written request only.
Patient Name(Required)
Parent or Guardian Name