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Patient Information

This intake form will give our doctor all the information he needs to approve your shot before you even walk through the door!
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date of Birth
Age*
Sex*
Address*

Street Address

Street Address Line 2

CityState / Province

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

Informed Consent for Treatment:

I have been informed about my chosen product, and understand the information regarding the risks and benefits of vitamins and amino acid injectables. I have had a chance to ask questions on treatment. I understand the possible complications of injection into the muscle; which are bruising at the site, numbness and tingling, dizziness, headaches, and possible fainting from the sight of blood. I understand that there may be a slight chance for sensitivities and reactions to any injectable solutions. I understand that I do not have an allergy to niacin. I understand that there may be numbness in the muscle that is injected for a period of time. I hereby release The B-12 Store and all its employees from all liabilities regarding my treatment with vitamin and amino acid injectables.
Signature*

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Today's date*

MonthDayYear
Today's date

Patient Information