VITAMIN INJECTION INTAKE FORM
Patient Name:
First Name
Last Name
DOB:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone:
Format: (000) 000-0000.
Home Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
CONSENT
Consent Statements
Injection, expected benefits, risks, and common side effects reviewed with patient.
Patient had opportunity to ask questions.
Patient understands treatment is elective and consents to administration.
Patient understands to notify staff immediately if they experience any unusual symptoms or reaction.
Patient Signature:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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