Vitamin B12 Consent Form

Vitamin B12 Consent Form
What are the possible benefits?
*Improved energy and stamina
*Improved sleep quality and duration
*Higher metabolism
*Improved mental clarity
*Balanced immune system

How often can I do the injections?
• Vitamin B12 shots are the most effective when taken at regular intervals. We recommend once weekly for 4 weeks, followed by once a month.

Facts about Vitamin B12 :
*Aging means we absorb less Vitamin B12 from food. It is estimated 85% of us come up short of the necessary B12 from our diet.
*Absorption of B12 in food requires a substance from our stomachs called intrinsic factor, the production of which decreases with age.
*Individuals with chronic fatigue or anemia require regular injections of vitamin B12 because the oral form may be unreliable.

Side effects and warnings:
• Some redness and swelling at the injection site may occur and should begin to clear up within 48 hours.
• Vitamin B12 is safe for most individuals. However, pregnant or lactating women should speak to their doctor prior to starting a B12 regiment.
• Sensitivity to cobalt and/or Vitamin B12 is a contraindication
• Clients with chronic liver and/or kidney dysfunction, Leber’s disease (hereditary eye disease) or abnormal red blood cells (megaloblastic anemia) should not take frequent B12 injections.

I HEREBY ACKNOWLEDGE THAT I HAVE FULLY DISCLOSED, TO THE BEST OF MY KNOWLEDGE, MY COMPLETE MEDICAL HISTORY AND HAVE ANSWERED ALL QUESTIONS IN THE MEDICAL HEALTH QUESTIONNAIRE A HONESTLY AND ACCURATELY AS POSSIBLE. DANIELA BOBSIN BEAUTY MEDICAL AESTHETICS IS NOT RESPONSIBLE FOR ANY ADVERSE EVENTS THAT OCCUR AS A RESULT OF FAILURE TO DISCLOSE HEALTH INFORMATION AS REQUESTED.

I acknowledge that I have had the opportunity to consult with Daniela Bobsin RN and have asked any questions that I may have related to the procedure I am about to undergo. Daniela Bobsin RN has reviewed my health history and medications with me, and I agree that I have not withheld any medical information from her or her Nurse Practioner. I have read through and understand all of the information, terms, complications, and conditions pertaining to the Vitamin B12 IM injection, and do herby provide my consent to undergo treatment: