Skinny Shot Injection Consent Form

  • "Skinny Shots" (B12 w/ Lipotropic) Injections Informed Consent

    Vitamin B-12 with Lipotropic helps maintain good health and has been shown to be beneficial in helping to: reduce stress, fatigue, improve memory, and cardiovascular health, and maintain a good body weight. It can also assist the body in converting proteins, fats, and carbohydrates into energy and is necessary for healthy skin and eyes.

    B12 injections are better absorbed by the body once they go directly into the blood stream. Alternatives to B12 injections are oral vitamins, B12 patch, lozenges, liquid drops, and nasal spray.

    B12 injections common side effects include but are not limited to:

    1. Risks: I understand there is a risk of mild diarrhea, upset stomach, nausea, a feeling of pain and a warm sensation at the site of the injection, a feeling, or a sense, of being swollen over the entire body, headache, and joint pain.

    2. If any of these side effects become severe or troublesome I will contact my physician immediately.

    3. I understand that although rare vitamin B12 injections can result in serious side effects. Although this is a relatively rare occurence, anyone taking vitamin B12 should be aware of the possibility. Uncommon side effects are much more serious than the common side effects of B12 injections, and such side effects should be reported to a physician to be evaluated for seriousness.

    4. Before starting vitamin B12 injections I will make sure to tell my physician and not perform the injection if I am pregnant, lactating or have any of the following conditions:
    • Leber's Disease
    • Kidney Disease
    • Liver Disease
    • An infection
    • Iron deficiency
    • Folic acid deficiency
    • Receiving any treatment that has an effect on bone marrow
    • Taking any medication that has an effect on bone marrow
    • An allergy to cobait or any other medication, vitamin, B complex dye, food or preservative, ascorbic acid USP, Thamine Hydrockloride USP, Robiflavin-5-Phosphate Sodium, Niacinamide USP poswder, Panthenol USP (DL) powder, Pyridoxine Hydrochloride, Cyanocabalamin Powder, Lidocaine Hydrochloride USP, Methionine USP (L) Powder, Inositol FCC Powder, Choline Chloride USP Powder, Sterile water, lipotropic or sulfur.

    5. I understand that certain herbal products, vitamins, minerals, nutritional supplements, prescription and non prescription medications may result in side effects when they interact with the B12 injection.

    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 B12 injections with the above understood. I hereby release the doctor, the person injecting the B12 and the facility from liability associated with this procedure.
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