Consent for Vitamin Injections

Consent for Vitamin Injections
Date *

Month Day Year
Date
Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Birthdate
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Email
example@example.com
Allergies to Medications *

No Yes (NOTICE: MIC Ultra injections contain a sulfa component if you have a sulfa allergy)
If your have medication allergies please list them here
This is to acknowledge that I have been informed and I understand that:
- I have read all of the foregoing information and that I understand that the ultimate responsibility for my health is my own.
- Any treatment or advice given to me as a patient is not mutually exclusive from any treatment or advice that I may receive now, or in the future, from another licensed health care provider.
- I am at liberty to seek or continue medical care from any health care provider of my choosing.
- I accept full responsibility for any fees incurred during care and treatment. I agree to fully discharge this responsibility at the time of the visit unless prior arrangements have been made.
- There are some slight health risks associated with treatment. These include but are not limited to: allergic reactions to supplements, side effects of medications, pain, bruising, infection, or injury from injections.
Client Signature *

Client Signature Clear
INTERNAL USE ONLY:
Nurse Practitioner:

SIG: 2ml IM MIC Ultra injection ongoing weekly as needed SIG: 1ml IM Methylcobalamin B12 1000 mcg/ml injection ongoing weekly as needed
Nurse Practitioner Signature:
Must signed by APC Nurse Practitioner BEFORE injection may be given
Should be Empty:

Consent for Vitamin Injections

INTERNAL USE ONLY: