Vitamin B and/or Amino Acid Injection Consent Form

Intravenous B-12 Vitamin and/or Amino Acid Injections Informed Consent

Intravenous B-12 vitamin and/or amino acid injections can help to maintain good health and have been shown to be beneficial in helping to:

·       Reduce stress and fatigue;

·       Improve memory and cardiovascular health; and

·       Maintain a healthy body weight.

They can also assist the body in converting proteins, fats and carbohydrates into energy, and are necessary for healthy skin and eyes. B-12 injections are better absorbed by the body as they go directly into the bloodstream. Alternatives to B-12 injections are oral vitamins, B-12 patch, lozenges, liquid drops and nasal spray.

Common side effects
If any of these side effects become severe or troublesome, I will contact my Provider immediately. Common side effects of intravenous B-12 vitamin and amino acid injections include, but are not limited to:

·       Diarrhea;         

·       Upset stomach;

·       Nausea;

·       Headache;       

·       Joint pain;                                

·       Pain and/or a warm sensation at the injection site; and/or

·       Swelling over the entire body.

Uncommon and dangerous side effects
I understand that, although rare, vitamin B-12 injections can result in serious side effects. Anyone taking vitamin B-12 injections should be aware of the possibility of these uncommon side effects. Uncommon side effects are much more serious than the common side effects of B-12 injections, and such side effects should be reported to a physician to be evaluated for seriousness. Uncommon and dangerous side effects include, but are not limited to:

·       Rapid heartbeat;          

·       Chest pain;                  

·       Flushed face;               

·       Muscle cramps;

·       Hives;                          

·       Skin rashes;                 

·       Dizziness;

·       Confusion;       

·       Rapid weight gain;                    

·       Tight feeling in the chest;                                  

·       Shortness of breath when there is no physical exertion;

·       Weakness;

·       Difficulty breathing and swallowing; and/or         

·       Unusual wheezing and coughing.

Before starting the injections
Before starting the injections, I will inform my Provider if I am:

·       Pregnant or lactating;

·       Taking any medication that has an effect on bone marrow; and/or

·       Receiving any treatment that has an effect on bone marrow.

Before starting the injections, I will inform my Provider if I have any of the following conditions:

·       An infection;                             

·       Allergy to cobalt or any medications, vitamins, dyes, foods or preservatives;

·       Liver disease;                           

·       Leber’s Disease;                      

·       Kidney disease; and/or             

·       An iron or folic acid deficiency.  

Before starting the injections, I understand that certain herbal products, vitamins, minerals, nutritional supplements, and prescription and non-prescription medications may result in side effects when they interact with the B-12 and amino acid injection.

Treatments
I understand that B-12 injection treatments can be administered once a month, once a week, or a different interval to be determined solely by the Provider.

I acknowledge that although good results are expected, they are not guaranteed, and I may be disappointed with the results of the treatments. Because of the nature of medicine, there cannot be any guarantee or warranty expressed or implied with regard to the results that may be obtained.

Informed consent documents are used to communicate information about the proposed treatment of a disease or condition along with disclosure of risks and alternative forms of treatment(s). The informed consent process attempts to define principles of risk disclosure that should generally meet the needs of most patients in most circumstances. However, informed consent documents should not be considered all-inclusive in defining other methods of care and risks encountered. Informed consent documents are not intended to define or serve as the standard of medical care. Standards of medical care are determined on the basis of all of the facts involved in an individual case and are subject to change as scientific knowledge and technology advance, and as practice patterns evolve. It is important that you read the above information carefully and have all of your questions answered before signing this consent.

I agree that this constitutes full disclosure, and that is supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs, and that I have had sufficient opportunity for discussion and to ask questions. I consent to this B-12 injection treatment today and for all subsequent treatments.