Sign Form

Consent Form

Intramuscular & Subcutaneous Injection
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Purpose of Treatment
I understand that I may receive one or more intramuscular or subcutaneous injections. These injections may include vitamins, medications, minerals or other substances as requested.
Procedure
Intramuscular injections are given in the muscle. Subcutaneous injections are given into the tissue under the skin. Injections will be administered by a licensed trained professional using sterile technique.
Possible Benefits
Benefits may include improved feelings of wellness, symptom relief and therapeutic effects depending on what is administered. Results are NOT guaranteed.
Consent

I confirm that I have disclosed all medical conditions, allergies, medications and supplements. Failure to disclose may increase risk of complications.
I have had the opportunity to ask questions. All questions have been answered. I voluntarily consent to receive intramuscular and/or subcutaneous injections. I understand I may withdraw consent at any time.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Consent Form