{"id":114,"date":"2020-10-29T17:40:13","date_gmt":"2020-10-29T21:40:13","guid":{"rendered":"https:\/\/myskincareclub.com\/forms\/?page_id=114"},"modified":"2020-10-29T18:00:53","modified_gmt":"2020-10-29T22:00:53","slug":"b12-consent-form","status":"publish","type":"page","link":"https:\/\/myskincareclub.com\/forms\/b12-consent-form\/","title":{"rendered":"B12 CONSENT FORM"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"114\" class=\"elementor elementor-114\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-3c452d7 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"3c452d7\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-f446404\" data-id=\"f446404\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-ccdfa57 elementor-widget elementor-widget-heading\" data-id=\"ccdfa57\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Vitamin B12 Consent Form<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-fb67206 elementor-widget elementor-widget-wp-widget-frm_show_form\" data-id=\"fb67206\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"wp-widget-frm_show_form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"frm_form_widget\"><div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_10_container\" >\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_vitaminb12consentform\" >\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">Vitamin B12 Consent Form<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"10\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_10\" id=\"frm_hide_fields_10\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"vitaminb12consentform\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_10\" name=\"frm_submit_entry_10\" value=\"7304d70deb\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/forms\/wp-json\/wp\/v2\/pages\/114\" \/><div id=\"frm_field_153_container\" class=\"frm_form_field  frm_html_container form-field\">What are the possible benefits?<br \/>\n*Improved energy and stamina<br \/>\n*Improved sleep quality and duration<br \/>\n*Higher metabolism<br \/>\n*Improved mental clarity<br \/>\n*Balanced immune system<\/p>\n<p>How often can I do the injections?<br \/>\n\u2022 Vitamin B12 shots are the most effective when taken at regular intervals. We recommend once weekly for 4 weeks, followed by once a month.<\/p>\n<p>Facts about Vitamin B12 :<br \/>\n*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.<br \/>\n*Absorption of B12 in food requires a substance from our stomachs called intrinsic factor, the production of which decreases with age.<br \/>\n*Individuals with chronic fatigue or anemia require regular injections of vitamin B12 because the oral form may be unreliable.<\/p>\n<p>Side effects and warnings:<br \/>\n \u2022 Some redness and swelling at the injection site may occur and should begin to clear up within 48 hours.<br \/>\n\u2022 Vitamin B12 is safe for most individuals. However, pregnant or lactating women should speak to their doctor prior to starting a B12 regiment.<br \/>\n\u2022 Sensitivity to cobalt and\/or Vitamin B12 is a contraindication<br \/>\n\u2022 Clients with chronic liver and\/or kidney dysfunction, Leber\u2019s disease (hereditary eye disease) or abnormal red blood cells (megaloblastic anemia) should not take frequent B12 injections.<\/p>\n<p>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.<\/p>\n<p>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:<\/p><\/div>\n<div id=\"frm_field_156_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_am79s\" id=\"field_am79s_label\" class=\"frm_primary_label\">Patient Name\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_am79s\" name=\"item_meta[156]\" value=\"\"  style=\"width:50%\" data-invmsg=\"Text is invalid\" class=\"auto_width\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_154_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_116ly\" id=\"field_116ly_label\" class=\"frm_primary_label\">Date\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_116ly\" name=\"item_meta[154]\" value=\"04\/14\/2026\"  style=\"width:50%\" maxlength=\"10\" data-frmval=\"04\/14\/2026\" data-invmsg=\"Date is invalid\" class=\"frm_date auto_width\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_155_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_bayay\" id=\"field_bayay_label\" class=\"frm_primary_label\">Signature\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div class=\"sigPad\" id='sigPad155' style=\"max-width:400px;\">\n\t<div class=\"sig sigWrapper\" style=\"height:150px;border-color:#BFC3C8;--bg-color:#ffffff;--active:#579AF6;--inactive:#eaeaea;--active-text:#ffffff;--inactive-text:#3f4b5b;--button-margin:22px;--button-size:20px;--button-padding:10px;--button-side-margin:22px;--icon:20px\">\n\n\t\t<ul class=\"sigNav\">\n\t\t\t\t<li class=\"drawIt\">\n\t\t\t\t\t<a href=\"#\" class=\"frm-active-sig-type\" title=\"Draw It\" aria-label=\"Draw It\">\n\t\t\t\t\t\t<svg  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>Submit<\/button>\r\n\r\n<\/div><\/div>\n<\/fieldset>\n<\/div>\n\n<\/form>\n<\/div>\n<\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Vitamin B12 Consent 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