B12 & MIC injection informed consent form

B12 & MIC INJECTION FORM

Youthful Reflections, LLC 3 Geyser St., Suite 7 Ennis, MT 59729 (406) 925-3036 rnjordanstone@youthfulreflectionsmt.com
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ALLERGIES (MEDICATIONS, TOPICALS, FOOD, ENVIRONMENTAL)
CURRENT MEDICATIONS AND SUPPLEMENTS
ARE YOU ALLERGIC TO SULFA OR COBALT?

YESNO
DO YOU HAVE LEBER'S DISEASE? (Leber Hereditary Optic Neuropathy)

YESNO
DO YOU HAVE LIVER IMPAIRMENT OR LIVER DISEASE (CIRRHOSIS, FATTY LIVER, HEPATITIS)?

YESNO
DO YOU HAVE KIDNEY IMPAIRMENT OR KIDNEY DISEASE?

YESNO
SELECT IF YOU HAVE ANY OF THE FOLLOWING

FATIGUETENDONITISLOW OR DEPRESSED MOODASTHMAIRRITABILITY OR MOODINESSHISTORY OF MIRGAINESWEIGHT ISSUESIMMUNOSUPPRESSIONPRENICOUS AMEMIATHYROID DISORDERSHEART DISEASEIBS / INFLAMMATORY BOWEL NUMBNESS/TINGLINGDIABETESPREGNANT / OR TRY TO CONCIEVEMEMORY LOSS / ALZHEIMER'SBREASTFEEDINGSLEEP DISORDERSANY INFECTIONOSTEOPOROSISPOLYCYTHEMIA VERAIRON DEFICIENCYTAKING METHOTREXATEHISTORY OF GOUTSELECT IF YOU HAVE ANY OF THE FOLLOWING:IRREGULAR HEATBEAT
IF YOU NEED TO EXPLAIN ANY HEALTH AILMENT SELECTED ABOVE OR ANY ADDITIONAL MEDICAL INFORMATION, DO SO HERE
HAVE YOU EVER HAD AN ADVERSE REACTION TO A B12, MIC OR OTHER INJECTION?

YESNO
REASON YOU ARE RECEIVING THIS INJECTION?
HOW DID YOU HEAR ABOUT US?
BEFORE THIS AND EVERY INJECTION, I WILL INFORM YOUTHFUL REFLECTIONS' SERVICE PROVIDER IF I HAVE ANY CHANGES IN HEALTH HISTORY OR HAVE ANY OF THE FOLLOWING:
- CHANGE IN HEALTH STATUS
- LEBER'S DISEASE
- LIVER DISEASE
- KIDNEY DISEASE
- ANY INFECTION
- IRON DEFICEINCY
- POLYCYTHEMIA VERA
- GOUT
- TAKING METHOTREXATE
- ALLERGY TO COBALT OR SULFA
BEFORE THIS AND EVERY INJECTION, I WILL INFORM YOUTHFUL REFLECTION'S SERVICE PROVIDER IF I HAVE ANY CHANGES IN HEALTH HISTORY OR HAVE ANY OF THE FOLLOWING: CHANGE IN HEALTH STATUS, LEBER'S DISEASE, LIVER DISEASE, KIDNEY DISEASE, ANY INFECTION, IRON DEFICEINCY, POLYCYTHEMIA VERA, GOUT, TAKING METHOTREXATE, OR NEW ALLERGY TO COBALT OR SULFA

I AGREE
I understand the recommended dose is 1-2ml intramuscularly with a weekly-monthly dose.

I AGREE
I certify that I am in good health and/or have my healthcare provider's approval.

I AGREE
B12 and MIC 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 rash/hives.

I UNDERSTAND
Most common side effects are redness and swelling and soreness around the site of injection lasting up to several days.

I understand
I release the service provider and all Youthful Reflections. LLC medical providers, nurses, employees, owners, managers, and directors from any liability arising from or in connection with this injection.

I AGREE
I request treatment with B12 and/or MIC. The injection and procedure were explained to me. Questions about the procedure were explained to my satisfaction. The information given to me is clear, and I understand the risk, benefits, and possible side effects of the treatment. I have read the above information about B12 and MIC injections.

I AGREE
Vitamin and nutritional supplements are not intended to diagnose, treat, cure, or prevent any illness or disease.

I UNDERSTAND
I grant Youthful Reflections, LLC, its representatives, and employees the right to take photographs or videos of me in connection with receiving any treatments from Youthful Reflections. I authorize Youthful Reflections, its assignees, and transferees to copyright, use, and publish the same in print or electronically. I agree that Youthful Reflections may use such photographs or videos of me with or without my name and for any lawful purpose, including for example such purposed as publicly, illustration, advertising, social media and web content.

I AGREEI do NOT agree
By signing below, I AM SATISFIED WITH THE EXPLAINATION and I hereby give my voluntary consent to this procedure and release Jordan Stone, RN BSN and her business staff from liability associated with the procedure.
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B12 & MIC INJECTION FORM