Consent Form

Consent To Treat

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

First Last

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 www.cocooninghealth.com, unless established sliding scale cost was established in writing (emailed from Cosima@cocooninghealth.com)

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.

Signature(Required)

Patient Name(Required)

First Last

Parent or Guardian Signature (for children under 18 and vulnerable adults under guardianship)

Parent or Guardian Name

First Last