I have truthfully answered all questions regarding my medical history and have informed the practitioner about any and all prescription medications and/or over the counter drugs I take, as well as any street or recreational drugs.
I understand that failing to inform the practitioner about my medical issues and/or drug use can lead to serious complications.
I acknowledge that I am responsible for any medical care I may have that is directly or indirectly related to the services provided by The Vitamin Bar Ltd. If I seek medical treatment for any side effects or reaction, it will be at my own expense.
I acknowledge and agree that the sole risk of injury or harm resulting in any manner from my voluntary participation in The Vitamin Bar Ltd. services rests entirely with me if I fail to disclose any of my health condition(s), medications, or drug use in advance of the services provided. I expressly represent and warrant to The Vitamin Bar Ltd. that I have never been diagnosed with or treated for any illnesses or conditions that may result in increased risk when participating in the services provided by The Vitamin Bar Ltd.
I understand that The Vitamin Bar Ltd. Bears no responsibility for and will not screen for, diagnose, monitor, or provide any care for such conditions.
I acknowledge that The Vitamin Bar Ltd. relies upon information provided by me in assessing my suitability to participate in the services provided.
There is no guarantee that IM injections will temporarily or permanently cure or resolve your hangover, effects of altitude sickness, dehydration, or viral illness. Please drink alcohol in moderation. Heavy drinking after treatment can lead to stomach irritation or other complications. Vitamin and micronutrient supplementation is not a cure for heavy drinking. Excessive drinking
can lead to alcohol poisoning and other serious medical problems. Always drink alcohol in moderation.
I acknowledge that I have been given the opportunity to discuss the nature and purpose of the treatment and the risks, complications, and consequences associated with the procedures. I am
aware that it is impossible to foresee or predict all possible risks, complications, and consequences, and I do not expect that the practitioner to anticipate or explain all associated risks. I waive any and
all claims related to the services provided and agree to hold The Vitamin Bar Ltd. harmless regarding any complications or consequences I experience during or following the service.
This document is intended to serve as confirmation of informed consent for IM injections as ordered by the practitioner. I have informed the practitioner of any known allergies to drugs or other
substances, or of any past reactions to anaesthetics. I have informed the practitioner of all current medications and supplements.
Vitamins are vital for our body’s normal function and are absolutely necessary for our growth, general-well being, and vitality. Except for a few exceptions, vitamins cannot be manufactured or synthesized by the body and their absence or improper absorption results in specific deficiency
diseases. Therefore it is important for our body to obtain vitamins from outside sources to battle against the chance for a deficiency. Latest researches indicate that many vitamins taken in large doses can have miraculous healing effects in a wide range of common complaints and illnesses.
Proper vitamin injections can supply the much needed nutrients your body needs to maintain and enhance normal bodily functions. Vitamin Injections are better absorbed by the body since they go directly into the blood stream. Alternatives to these injections are Oral Vitamins, Capsules, Liquid drinks, Lotions, Topical Creams, and Mouth Sprays.
Vitamin Injections common side effects include but are not limited to:
1. Risks: I understand there is 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 are much more serious than the common side effects of Vitamin injections, and such side effects should be reported to a physician to be evaluated for seriousness. Uncommon and dangerous side effects include:
• headache
• nausea
• diarrhea
• bloating
• constipation
• indigestion or heartburn
• abnormal bleeding
• gastrointestinal hyperactivity
• chest pain
• flushed face
• chills
• fever
• upset stomach
• rapid heartbeat
• heart palpitations
• restlessness
• muscle cramps and weakness
• dizziness
4. I understand the possibility of having an allergic reaction to any of the ingredients found within the Vitamin injection is quite plausible and that I should communicate with my Physician if I have any known allergic reactions to foods, dyes, preservatives, or any other substances. If I experience any of these following signs of allergic reactions I should immediately consult my primary health care Physician and discontinue further use of the product. Signs of allergic reactions include, but not limited to:
• Itching of skin
• Hives
• Rashes
• Wheezing
• Difficulty breathing
• Swelling of mouth or throat
5. When medications are taken in conjunction with the Vitamin Injection, drug interactions could occur. These interactions can either increase your risk of bleeding or block the absorption of the Vitamins into the body. These medications at the time of your injection should either be discontinued or be consulted with by a Physician. Some of the medications that may cause drug interactions include, but are not limited to:
• Heparin (Fragmin, Lovenox, Innohep…ect.)
• Antithrombin (A Tryn, Thrombate III)
• Argatroban
• Aspirin
• Ibuprofen
• Dipyridamole (Persantine)
• Bivalirudin (Angiomax)
• Clopidogrel (Plavix)
• Warfarin (Coumadin, Jantoven)
• Nonsteroidal anti-inflammatory drugs (Ibuprofen,…etc.)
6. 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.
7. I am aware that other unforeseeable complications could occur. I do not expect the practitioner to anticipate and/ or explain all risk and possible complications. I rely on the practitioner to exercise judgment during my procedure. I understand the risks and benefits of the procedure, and have had the opportunity to have all my questions answered. I understand that I have the right to consent or refuse any proposed treatment at any time prior to its performance.
GDPR & DATA PROTECTION:
I understand that my information be kept strictly confidential and will not be shared with anyone but with The Vitamin Bar Ltd. By signing below I am agreeing to information being shared with The
Vitamin Bar Ltd.