I request treatment with vitamin injection(s). The injections and its contents have 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 certify that I do not have an allergy to Sulfa, Bactrim or Cobalt (B12).
- I certify that I do not have liver or kidney disease and/or impairment.
- I certify that I am not pregnant or breast feeding.
- I certify that I have never had any adverse reaction to a vitamin injection?
- I certify that before this and EVERY injection I will inform Give It A Shot staff if I have any of the following:
- Kidney/Liver Disease
- An Infection
- Cobalt/Sulfa/Bactrim Allergy
- Pregnant or Breastfeeding
Informed Consent Treatment:
I certify that I am in good health and/or have my physician’s approval. I have read the above information about the vitamin injection(s). I have the opportunity to ask questions that I may have had before receiving this injection(s). I understand the benefits and risks regarding this injection(s). I release Give It A Shot, their providers, and employees from any and all liability arising from or in connection with this injection(s). I understand that the most common side effects of these injection(s) are redness/swelling and tenderness at the injection site lasting up to a few days. I also understand that, although rare, other possible adverse reactions, can include: mild diarrhea, anxiety/panic attacks, heart palpitations, insomnia, breathing problems, chest pain, skin rashes/hives.
I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. By signing below, I acknowledge that I have read the foregoing informed consent and agree to the treatment with its associated risks. I hereby give consent to perform this and all subsequent vitamin Injections with the above understood. I hereby release Give It A Shot, the person injecting the vitamins, and the facility from liability associated with this procedure.
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