Cosmetic Procedure Form

Removal of the following benign lesion(s) is not medically
necessary and therefore cosmetic in nature. Removal of
these lesions is not covered by the insurance companies.

Payment for any procedure is expected at the time of each
visit.

• Skin tags
• Small cysts, not inflamed
• Benign appearing moles
• Benign keratoses i.e. seborrheic keratoses
• Benign age spots
• Angiomas i.e. qherry angiomas
• All lesions deemed benign and cosmetic by the physician
• All laser treatments
• Leg vein therapy
• Cosmetic skin care products dispensed by our aesthetic specialists

Please do not ask the physician to code benign procedures
through your insurance as that is considered to be insurance
fraud.

Ask the physician for a cosmetic quote if you would like to
have a benign lesion removed.