b12 Consent Form

VITAMIN B12 CONSULTATION

AND CONSENT FORM

Please answer the consultation questions appropriately. This questionnaire will guide us for your upcoming treatment.

Full Name *

Phone *

Email *

Date of birth *

Medical History

Do you have any allergies? If yes, please specify: *

Are you currently taking any medication? *

Yes

Do you have any history of skin diseases, disorders, or issues? If yes, please specify: *

Are you currently pregnant or nursing? *

Yes

Do you have a history of keloid scarring? *

Yes

Consent and Acknowledgment

B12 (Methylocobalamin)

It is recommended for stress and/or anxiety
It may provide you with energy, aid weight loss, improve higher metabolism, improve sleep, balanced immune system function.
While results differ from each individual the effect of the B12 shot usually is around 48-72 hrs.
Many individuals will need around 1 shot of vitamin B12 three times within 3 months for the full affect and then once every 3 months to maintain the ongoing effect.

Possible side Effects

Some redness and swelling at the injection site may occur. This should start to get better with forty eight hours.
In rare cases, B12 can cause diarrhoea, peripheral vascular thrombosis, itching, anaphylactic shock, transitory exanthem and hives.
People with chronic liver and/or kidney dysfunction should NOT take frequent B12 injections; therefore we ask that you provide us with the most resent copy of lab work, which reflects liver and kidney function.

I am 18 years or over.

I understand that there is no refund for any of the services performed.I am fully aware that this procedure is made voluntarily, and I have had the opportunity to ask questions and have them answered to my satisfaction.
I have been informed about the aftercare instructions and commit to following them diligently.
I release the practitioner and the establishment from liability if any complications or unfavourable results arise from the treatment.
I understand the costs associated with this procedure and accept full responsibility for these costs.
I certify that I have voluntarily sought the services provided and consent to the treatment.

Signature *

By signing and ticking this, I have read and agree to the clinic procedures of the treatment(s) that I have availed and abide from the instructions.