Intramuscular (IM) Injection Consent Form
Please read and agree to each statement.
I have the right to be informed about my health condition and treatment so that I may make an informed decision, whether or not to undergo Intramuscular injection after knowing the risks and hazards involved. If I do not feel comfortable with the IM injection, I have the right to refuse treatment.
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Please Select
Agree
I have informed the provider of any known allergies to medications or other substances and of all current medications and supplements. I have fully informed the nurse and/or provider of my medical history.
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Please Select
Agree
Allergies:
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Please Select
No known allergies
See List of Allergies
List of Allergies
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I understand intramuscular vitamin injections and any claims made about these injections have not been evaluated by the US Food and Drug Administration (FDA) and are not intended to diagnose, treat, cure, or prevent any medical disease. These treatments are not a substitute for your routine medical care.
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Please Select
Agree
I understand that the procedure involves inserting the muscle and injecting the prescribed solution.
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Please Select
Agree
I am aware that other unforeseeable complications could occur. I do not expect the provider(s) to anticipate and/or explain all risk and possible complications. I rely on the provider(s) to exercise judgment during the course of treatment with regards to my procedure. I understand the risks and benefits of the procedure and have had the opportunity to have all my questions answered.
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Please Select
Agree
I understand that all payments for services to San Antonio Prime Wellness are non-refundable and all sales are final.
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Please Select
Agree
Today's Date
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Month
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Year
Date
Date of Birth
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Month
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Day
Year
Date
Name
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First Name
Last Name
Signature - Your signature signifies your consents to the use and disclosure of your PHI by our office during treatment, billing, reimbursement, and medical office operations. You agree and consent that your PHI may be communicated to you via telephone or email (encrypted or unencrypted).
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