MICC Injection Consent Form:
By signing below, I certify that I understand the following information:
- This is a supplemental treatment and is most effective when utilized in the setting of healthy eating and activity habits
- Each patient responds differently to medicine and may respond differently from one treatment to the next
- As with all medicines, results are temporary and regular dosing is necessary
- The length of time the medication lasts varies in each patient
- NO guarantee can be made with regard to the results and length of time it lasts
- There are some risks with any medical treatment
- Weight loss can be inconsistent from one week to the next
The following are possible risk factors with MICC injections:
- Pain or bruising, redness, bleeding at the injection site (these are usually minimal and dissipate in minimal amount of time)
- Some people may experience allergic reaction to the injections.
- Stomach upset and urinary problems (urge incontinence), diarrhea may occur for some people
- It has been reported that B12 can cause peripheral vascular thrombosis, itching
- Nausea
- Random, short lasting body pains or joint aching
By signing below, I certify I have had the opportunity to have all of my questions answered. I will inform my practitioner of any changes in my medical history, current medications, and/or any changes relevant to this procedure prior to any further treatments. I have read and understand the ingredients, risks, and benefits of the injection being administered to me and I consent to this treatment. I further acknowledge that I am taking this injection of my own accord. I agree to release the facility and the medical practitioner from any liability should complications arise from this procedure.
I also certify by signing below that should I develop a side effect or allergic response to this injection, I will notify the provider and pursue medical care as recommended by that provider.