Vitamin B12, B Complex and Lipo B Injection Informed Consent Form Name * First Name Last Name Email * Phone (###) ### #### Date MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Check any of the following you have/had suffered from Fatigue Depressed Mood Anemia Heart Disease Diabetes Dementia/Alzheimer's Osteoporosis Sleep Disorders Asthma Allergies Migraines Weight Issues Immunosuppression Thyroid Disorders IBS Numbness/Neuropathy Autoimmune Blood Disorders Nutrient Malabsorption Digestive Issues Crohn's/Colitis Please explain checked items Other Medical Concerns ALL Prescriptions/supplements taken within the past 2 weeks Some of the medications that interfere with B adsorption: Antibiotics, Proton Pump Inhibitors (Prevacid, Prilosec, Pepicid) Birth Control Pills, Metformin. Nicotine and Gut health may also be causes of malabsorption. I certify that I currently do not have any of the following conditions and will notify the injector prior to any injections if this status changes at any time. Lebers Disease, Liver Disease, ANY infection or illness, iro Deficiency, Taking Methotrexate, Pregnancy/Breast Feeding, Cobalt/Sulfa Allergy, Polycythemia or an Blood or bleeding disorder, Gout, Mental Instability, Covid-19, Surgery or medical exam with lab within 2 weeks. Muscle soreness and tenderness is common after the injection, and is not uncommon to last a few days depending on injection site. Injections are completed in a series of 4 and start weekly, then bi weekly, then 4 to 4 times a month. Maintenance will be determined by injection effects. I certify that I am in good health or have my doctors consent to begin Vitamin B injections. I have read the above information and have had all my questions answered and feel comfortable receiving the injection. I release epic MedSpa and its Doctors, and employees from any and all liability arising from or in connection to this injection. Vitamin B is considered safe and non toxic even when taken in high doses, however I do understand it is possible to have an adverse reaction. Though rare, symptoms can include diarrhea, heart palpitations, anxiety/panic attack, insomnia, breathing problems, hives/rashes. By submitting this form, I understand and acknowledge all of the aforementioned information. Thank you!
