Vitamin Injection Consent Form

Name*

DOB*

How did you hear about us?

Email address*

example@example.com

Contact #*

Allergies*

Home Medications (NA for none)*

Have you ever had any adverse reaction to a vitamin or an injection?*

YesNo

Vitamin injections maintain good health and have been shown to be beneficial in helping to: Reduce stress, fatigue, improve memory and cardiovascular health and maintain a good body weight. It can also assist the body in converting proteins, fats and carbohydrates into energy and is necessary for healthy skin and eyes.

Vitamin injections are better absorbed by the body since they go directly into the bloodstream. Alternatives to vitamin injections are oral vitamins, patches, lozenges, liquid drops, and nasal spray.

1. Risks: I understand there is a risk of mild diarrhea, upset stomach, nausea, a feeling of pain and a warm sensation at the site of the injection, a feeling. or a sense, of being swollen over the entire body. headache and joint pain.

2. If any of these side effects become severe or troublesome, I will contact my physician immediately.

3. I understand that although rare, vitamin injections can result in serious side effects. Although this is a relatively rare occurrence, anyone taking vitamin injections should be aware of the possibility. Uncommon side effects include: rapid heartbeat, chest pain, flushed face, muscle cramps and weakness, difficulty breathing and swallowing, dizziness, confusion, tight feelings in the chest, hives, skin rashes, shortness of breath when there is no physical exertion and unusual wheezing and coughing.

4. Before starting Vitamin injections, I will make sure to tell the nurse or medical professional if I am pregnant, lactating, or have any of the following conditions: Leber's disease, Kidney disease, Liver disease, An infection, Iron deficiency, Folic acid deficiency, Receiving any treatment that has an effect on bone marrow, Taking any medication that has an effect on bone marrow, An allergy to cobalt or any other medication, vitamin, dye, food or preservative.

5. I understand that certain herbal products, vitamins, minerals, nutritional supplements, prescription and non- prescription medications may result in side effects when they interact with the vitamin injection.

6. I understand that there are no Refunds for injections or injection bundles. There is no refunds for gift certificates.

7. We require a 24hour advanced notice for Cancellations and ask that you please reschedule your appointment within one hour of your appointment beginning or you may be charged a cancellation fee.

I have read the above information about the injections. I understand the benefits risks of taking Vitamin injections. Knowing and understanding the risks involved with particitapation in Vitamin Injections, I hereby voluntarily and willingly assume responsibility for all risks associated with my participation in Vitamin Injections. I release Drip into Wellness and their nurses, doctors, employess, directors, officers, and agents from any and all liability arising from or in connection with the Vitamin Injection and herby forever realease, hold harmless, and discharge Drip into Wellness and the officers. *

Initial

I understand that Drip into Wellness does not offer Acute/Urgent Care Services or Primary Care Provider Services. I understand if at any time I am faced with a medical emergency I will contact Emergency Medical Services by dialing 911. *

Initial

Client Signature*

I understand that vitamins and nutritional supplements are not intended to diagnose, treat, cure, or prevent any diseases or illnesses.*

Initial

Print Name*

Date*

Date

Time*

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