I request treatment with B12. The injection of B12 has been explained to me and my questions regarding such treatment have been answered to my satisfaction. The information given to me has been in clear terms and I understand the risks, benefits, possible side effects and complications of the treatment.
• I understand the recommended dose for B12 is 1 to 2ML intramuscular weekly.
• I understand that possible side effects can include rapid heartbeat/chest pain/tightness, difficulty breathing, swallowing/shortness of breath, dizziness/confusion, hives/skin rash irritation at the site, infection, bruising, and irritation and tenderness at the injection site.
• I understand that although rare, some of the risks include mild diarrhea, upset stomach, nausea, a feeling of irritation/warmth at the site of the injection.
• I certify that I do not have an allergy to sulfa or cobalt.
• I certify that I do not have a liver or kidney impairment that I am aware of or any of the other contraindications listed. Before this and EVERY injection I will inform a Hydrate Drip Therapy team member if I have any of the following
Circle any that apply:
Pregnant or breastfeeding
Leber's Disease
Kidney Disease
Liver Disease
Blood Disorder
Cobalt/Sulfa Allergy
History of Gout
Any Infection
I have read the above information about the B-12 injection. I understand the benefits and risks of taking B12 injections. I release Hydrate Drip Therapy and their doctors, and employees, directors, from any and all liability arising from or in connection with this injection.
Vitamin b12 is safe and non-toxic even when taken in high doses, however I understand that it is possible that I could have an adverse reaction, though rare they can include: mild diarrhea, anxiety/panic attacks, heart palpitations, insomnia, breathing problems, chest pain, skin rashes/hives.
Most common side effects are redness/swelling and soreness around the injection site lasting up to a few days.
We do not offer Acute/Urgent Care Services, nor do we offer Primary Care Provider Services. We strongly recommend all of our clients to form a relationship with a Primary Care Provider and have regular check-ups. If at any time you are faced with a medical emergency, please contact your Primary Care Provider, report to the nearest Emergency Department or Urgent Care Center or Activate Emergency Medical Services by dialing 911. Vitamins and nutritional supplements are not intended to diagnose, treat, cure, or prevent any diseases or illnesses.
