B Complex, B12 & MIC Injection Consent and Release Form

B Complex, B12 & MIC Injection Consent and Release Form

Youthful Reflections, LLC
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Emergency Contact: Name, Relationship and Phone*
Allergies (medication, food and environmental). *
Are you allergic to Sulfa or Cobalt?*

YesNo
Do you have Leber’s Disease?*

YesNo
Do you have liver impairment or liver disease (Cirrhosis, Fatty Liver, Hepatitis...etc)?*

YesNo
Do you have kidney impairment or kidney disease?*

YesNo
Select if you have any of the following:

FatigueLow or depressed moodIrritability or moodinessWeight issuesPernicious AnemiaHeart DiseaseDiabetesMemory loss/Alzheimer’sSleep disordersOsteoporosisTendonitisAsthmaAllergiesHistory of MigrainesImmunosuppressionThyroid disordersIBS/Inflammatory bowelsNumbness/tingling of bodyPregnant or trying to become pregnantBreastfeedingAny infectionIron deficiencyPolycythemia VeraHistory of GoutTaking Methotrexate
If you need to explain any health ailment selected above, do so here.
Other pertinent family medical history we should know about.
Have you ever had an adverse reaction to a vitamin or injection?*
Current medications and supplements taken and their dosages. Include any medicated topical creams or ointments.*
Reason you are interested in receiving this injection?*
Referred By (referrals receive discounts*)
*Referral Program: If you refer someone and they come in to receive treatment, you will receive 10% off your next total treatment! Remember, they have to mention you referred them to receive your discount.
Before this and EVERY injection, I will inform the service provider if I have any the following:
- Change in my health status
- Leber's Disease
- Liver disease
- Kidney disease
- Any infection
- Iron deficiency
- Polycythemia Vera
- History of Gout
- Taking Methotrexate
- Cobalt/Sulfa allergy
I agree
I request treatment with B Complex, B12 or MICB12. The injection was explained to me. My questions about the procedure were explained to my satisfaction. The information given to me is clear, and I understand the risks, benefits and possible side effects of the treatment.
I understand the recommended dose is 1-2mL intermuscular with a weekly - monthly dose.

Possible side effects can include: irritation, infection, bruising and tenderness around the injections site.
I agree
I certify that I am in good health and/or have my physician’s approval. I have read the above information about the B-Complex, B12 and MIC injection. I have had the opportunity to ask my personal healthcare provider questions that I may have had before receiving this injection. I understand the benefits and risks of this injection. I release the service provider and all Youthful Reflections medical providers, nurses, employees, owners, managers and directors, from any and all liability arising from or or in connection with this injection.

Vitamin B complex, B12 and MIC is safe and non-toxic even when taken in high doses; however, I understand that it is possible that I could have an adverse reaction, though rare, they can include: mild diarrhea, anxiety/panic attacks, heart palpitations, insomnia, breathing problems, chest pain, skin rashes/hives.

Most common side effects are redness/swelling and soreness around the injection site lasting up to a few days.

We do not offer Acute/Urgent Care Services nor do we offer Primary Care Provider Services. We strongly recommend all of our clients to form a relationship with a Primary Care Provider and have regular check-ups. If at any time you are faced with a medical emergency, please contact your Primary Care Provider, report to the nearest Emergency Department or Urgent Care Center, or Activate Emergency Medical Services by dialing 911.

Vitamin and nutritional supplements are not intended to diagnose, treat, cure or prevent and illness or disease.
I agree
Today’s Date*

MonthDayYear
Date
Signature

Clear
Should be Empty: