Vitamin Injection Consent

Name*

First NameLast Name

Are you a new client?

YesNo

Email*

Phone Number*

Please enter a valid phone number.

Birth Date*

MonthDayYear

Gender*

MaleFemale

List medical conditions/history

List medications

Allergies: food and/or medications*

YesNo

List allergies:

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

YesNo

If yes, please elaborate:

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 practitioner 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.

Initials*

I have read the above information about the injections. I understand the benefits and risks of taking Vitamin injections. Knowing and understanding the risks involved with participation in Vitamin injections, I hereby voluntarily and willingly assume responsibility for all the risks associated with my participation in Vitamin injections. I release HydraDrip and their nurses, doctors, employees, directors, officers, and agents from any and all liability arising from or in connection with the Vitamin injection and hereby forever release, hold harmless, and discharge HydraDrip and the officers.

Initials*

I understand that HydraDrip 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.

Initials*

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

Vitamin Injections - Buy 4, Get 1 Free

B12

MICC

Glutathione

Tri Immune Booster

Toradol

Amino Blend

Name of Guardian (if minor)

First NameLast Name

Client Signature/Signature of Guardian (if minor)*

Date

Time

Hour Minutes

AM/PM Option