Vitamin B12 Injection Informed Consent Form

This form is intended to provide you with an overview of your treatment today, to explain the risks and possible side effects of such treatment, and obtain your consent for today’s treatment. Please read through this form in its entirety and complete it to the best of your knowledge prior to receiving any treatment. If you have any questions regarding the information in this form, please consult the provider prior to receiving today’s treatment.

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Vitamin B12, also known as cobalamin, is an essential nutrient that helps your body form red blood cells, aids in nerve function, and helps in the production of DNA. B12 can naturally be found in high protein foods, such as meats, poultry, eggs, seafood, nuts, seeds, peas, beans, lentils, and soy products. People who do not get enough B12 naturally (such as those with anemia, vegetarians/vegans, people with chronic fatigue,etc.), may choose to supplement B12 orally (by consuming pills) or by injection (a shot into your muscle).

Vitamin B12 injections are given intramuscularly (directly into the muscle), usually in the upper arm or thigh. To start, the healthcare provider will clean the injection site, insert the needle into your muscle, and inject the vitamin, which you may feel as a quick pinch. B12 shots are typically more effective than oral B12 supplements because the vitamin goes directly into your bloodstream, ensuring better absorption.
Vitamin B12 injections can help to improve a variety of conditions including: stress,chronic fatigue, memory, heart health, hormone imbalance, muscle weakness, nerve pain. They are also good for maintaining healthy skin and eyes, maintaining healthy body weight, improving mood, and aiding the body in converting food into energy.

Vitamin B12 injections are generally considered safe and serious side effects are rare. Potential side effects and risks include, but may not be limited to: mild discomfort, pain, bruising or swelling at the injection site, dizziness, headache, mild diarrhea, rapid heartbeat, flushed face, muscle cramps, chest pain, and although rare, allergic reactions (itching, hives/rash, difficulty breathing, or swelling of the face and throat). This list is not meant to be inclusive of all possible risks associated with the treatment as there are both known and unknown side effects associated with all injectable treatments.

Please let your healthcare provider know if you have any of the following conditions, as
you may not be a candidate for B12 injections:
- Pregnancy or breastfeeding
- Leber’s disease
- Kidney disease
- Liver disease
- Abnormal red blood cell count
- Bone marrow issues
- Hypokalemia (low potassium levels)
- Active infection
- Iron deficiency
- Folic acid deficiency
- Bone marrow treatments
- Allergy to cobalt
- Previous adverse reaction to B12 injections

The following medications may reduce the body’s ability to absorb Vitamin B12: birthcontrol, antibiotics, nicotine, H2-blockers, cobalt irradiation, colchicine, colestipol, metformin, potassium chloride, and proton pump inhibitors. It is important to let your healthcare provider know if you are currently taking any of these medications prior to receiving any B12 injections. Although it is impossible to list every potential risk and complication, the above are common known contraindications to the treatment. It is your responsibility to fully and accurately disclose your medical history prior to treatment. If you have any of the conditions listed above or any other health issue or concern, you should bring it to the attention of your provider prior to receiving any treatment.

Vitamin B12 injections are a strictly voluntary treatment. The treatment is not necessary or required. The alternative forms of treatment include not having the injections, taking oral B12 supplements, nasal B12 sprays, dietary adjustments, and/or B12 fortified foods and drinks. Although, it is important to note that such alternative treatments can present their own risks and potential complications.

After your treatment is complete you can generally resume normal activities. It is important to stay hydrated and monitor for any adverse reactions. You should follow any additional instructions given to you by your healthcare provider.

It is important to note that while many individuals experience positive effects from
Vitamin B12, the results are not guaranteed and results can vary depending on factors such as lifestyle, diet, and overall health status. For some people, achieving desired outcomes may require multiple injections on a regular basis to sustain the benefits over time.

Vitamin B12 injections require payment at the time of service. They are not reimbursable by government or private healthcare insurance providers.

Please intial next to each statement:

I consent and authorize the administration of Vitamin B12 injections on metoday.

I have received, reviewed, and understand this Consent Form and have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction.

I certify that I have read, or have had read to me, the contents of this Consent Form.

I understand the risks and potential side effects associated with VitaminB12 injections and understand that results cannot be guaranteed.

I have, to the best of my knowledge, given an accurate and complete account of my medical history, including, without limitation, recent procedures, health issues, all known allergies, prescription and OTC drugs, supplements, and products I am currently taking or using topically.

I understand that Vitamin B12 injections are an elective treatment and alternative treatment options have been explained to me

I have been provided with and understand the aftercare instructions and am aware that not following the instructions can lead to unsatisfactory results and potential complications.

I understand that the healthcare provider reserves the right to refuse to perform treatments on anyone whom she/he deems to have a condition for which Vitamin B12 injections are contraindicated.

I am over the age of 18.

I am not under the influence of alcohol or drugs.

I am currently pregnant or breastfeeding.

I , First Name Last Name , certify that information provided by me in this form is accurate and correct to the best of my knowledge. I have read and understand this from in its entirety. I voluntarily consent to today's treatment.

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Vitamin B12 Injection Informed Consent Form

Patient Information

About the Injections

Side Effects & Risks

Contraindications

Alternative Treatments

Post Treatment

Results

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Informed Consent

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