Vitamin B12 Injection Intake Form
Please complete this form to provide your health information and consent before receiving a Vitamin B12 injection.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have any known allergies?
*
No known allergies
Yes (please specify below)
If yes, please list your allergies (write N/A if none)
*
Are you currently taking any medications or supplements?
*
No
Yes (please specify below)
If yes, please list all current medications and supplements (write N/A if none)
*
Have you ever had a reaction to an injection or vaccination?
*
No
Yes (please describe)
Reason for requesting Vitamin B12 injection
*
Please select your appointment date and time
*
Signature (Please sign below to confirm your consent)
*
Submit Intake Form
Submit Intake Form
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