Vitamin B-12 helps maintain good health and has been shown to be beneficial in helping to: Reduce stress, fatigue, improve memory and cardiovascular health, and maintain a a good body weight. It can also assist the body in converting proteins, fats and carbohydrates into energy and is necessary for healthy skin and eyes.

B12 Injections are better absorbed by the body since they go directly into the blood stream. Alternatives to B12 injections are Oral Vitamins, B12 Patch, Lozenges, Liquid drops and Nasal Spray.

B12 Injections common side effects include but are not limited to:

1. Risks: I understand there is risk of mild diarrhea, upset stomach, nausea, a feeling of pain and a warm sensation at the site of the injection, a feeling, or a sense, of being swollen over the entire body, headache and joint pain
2. If any of these side effects become severe or troublesome I will contact my physician immediately
3. I understand that although rare Vitamin B12 injections can result in serious side effects. Although this is a relatively rare occurrence, anyone taking vitamin B12 injections should be aware of the possibility. Uncommon side effects are much more serious than the common side effects of B12 injections, and such side effects should be reported to a physician to be evaluated for seriousness. Uncommon and dangerous side effects include:
   
   • rapid heartbeat
   • chest pain
   • flushed face
   • muscle cramps and weakness
   • difficulty breathing and swallowing
   • dizziness
   • confusion
   • rapid weight gain
   • tight feelings in the chest
   • hives, skin rashes
   • shortness of breath when there is no physical exertion and unusual wheezing and coughing.
4. Before starting vitamin B12 injections I will make sure to tell my Physician if I am pregnant, lactating or have any of the following conditions.
   • Leber’s Disease
   • Kidney disease
   • Liver disease
   • An infection
   • Iron deficiency
   • Folic acid deficiency
   • Receiving any treatment that has an effect on bone marrow
   • Taking any medication that has an effect on bone marrow
   • An allergy to cobalt or any other medication, vitamin, dye, food or preservative
5. I understand that certain herbal products, vitamins, minerals, nutritional supplements, prescription and non prescription medications may result in side effects when they interact with the B12 Injection.
6. Treatments: Can be once a month, Once a week, Twice a week and will be determined by the provider.

I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. vitamin injections are strictly out of pocket and we don’t not accept insurance. I further agree in the event of non- payment, to bear the cost of collection, and/or Court cost and reasonable legal fees, should this be required.

Your consent and authorization for this elective procedure is strictly voluntary. By signing this informed consent form, you hereby grant authorization to our medical staff to perform and/or to administer any related treatment as may be deemed necessary or advisable in the diagnosis and treatment of your condition.

The nature and purpose of this elective procedure and the complications and side effects have been fully explained to me. Alternative treatments and their risks and benefits have been explained to me and I understand that I have a right to refuse treatment. I agree to adhere to all safety precautions and instructions after the treatment. I have been instructed in and understand post treatment instructions and have been offered a written copy of them. I understand that no refunds will be given for treatments received. No guarantee has been given by anyone as to the results that may be obtained by this treatment.

I have read this informed consent and certify that I understand its contents in full. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I have had enough time to consider the information given me and feel that I am sufficiently advised to consent to this procedure. I accept the risks and complications of the procedure. I certify if any changes occur in my medical history I will notify the office.

I hereby give my voluntary consent to this elective procedure and release the facility, medical staff, and specific technicians from liability associated with the procedure. I certify that I am a competent adult of at least 18 years of age and am not under the influence of alcohol or drugs. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns.

I agree, if I should have any questions or concerns regarding my treatment / results I will notify this office at immediately so that timely follow-up and intervention can be provided.