Vitamin B12 (Cyanocobalamin) Injection

I certify that I am at least 18 years old, or legal guardian of said patient and hereby give my consent to the staff of ShotRx, LLC to administer the Vitamin B12 injection listed below and to file the claim with my insurance if applicable. If I am 12 to 17 years old, I understand that I must have a written or verbal prescription from my doctor in order for me to receive a vaccination or injection at ShotRx, LLC. I understand the risks and benefits of this injection and choose to assume that risk. As with all medical treatment, I know there is no guarantee that I will not experience an adverse side effect from this injection. I fully release and discharge ShotRx, LLC from any liability for illness, injury, loss or damage that may result there from.

Patient or Legal Guardian Signature (Legal Guardian Signature required for patients 12-17 years of age) No injections will be given to those <12yrs.

Location

Patient’s Name*

First NameLast Name

Date of Birth*

DOB

Age*

Sex*

MaleFemale

Address*

City*

State*

AB

Zip*

Phone*

Email*

example@example.com

Physician*

1. Have you ever had a Vitamin B12 injection before?*

YESNO

2. Do you have an allergy to any B12 injection ingredient?*

YESNO

3. Have you had a serious reaction to any B12 injection before?*

YESNO

4. Do you have liver or kidney problems? If unsure, tell your pharmacist.*

YESNO

5. Has your doctor told you that you have illness of your eyes called Leber's disease?*

YESNO

6. Have you had a mastectomy (breast removal)?*

YESNO

7. PLEASE PHONE ME WHEN MY NEXT DOSE IS DUE*

YESNO

Patient or Legal Guardian Signature (Legal Guardian Signature required for patients 12-17 years of age) No injections will be given to those <12yrs.*

Date*

Date