Lipotropic injections and B12 Informed Consent

Lipotropic Injection and B12 Informed Consent

Name

You Acknowledge That

1. That if I begin to have side effects, I will contact (LLC NAME/PROVIDER NAME) immediately and notify them of what is happening. 2. I understand that although rare, vitamin B12 injections can result in serious side effects. If these occur, you should follow up with a medical provider or go to the emergency department immediately. Uncommon and dangerous side effects include: rapid heartbeat, chest pain, flushed face, muscle cramps, weakness, difficulty breathing and swallowing, dizziness, confusion, rapid weight gain, feeling of tightness in the chest, hives and rashes, shortness of breath when there is no physical exertion and unusual wheezing and coughing. 3. Before starting vitamin B12 and lipotropic injections I agree to make my (LLC NAME/PROVIDER NAME) aware if I have any of these conditions: Leber’s Disease, liver disease, kidney disease, iron deficiency, folic acid deficiency, cardiovascular disease, receiving any treatment or taking any medication that has an effect on bone marrow, or drug/supplement allergies. 4. I understand that there could be interactions with B12 and lipotropic injections and certain medications/supplements. 5. The use of B12 and lipotropic injections on a weekly to biweekly basis without a documented B12 deficiency is considered off label use and has not been FDA approved for increasing energy levels and weight loss. 5. Caution is advised while taking B12 if you have a sulfa allergy. By signing below, I acknowledge that I have read the informed consent and agree to the treatment with its associated risks. I hereby give consent for B12 and/or lipotropic injections. I agree to inform my medical provider immediately if I have any side effects. I hereby release
(LLC NAME), (MEDICAL PROVIDER) and the person injecting the B12 and lipotropic injection of any damages or liability if anything was to occur.
Patient Signature(Required)
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