Vitamin B12 Intake & Consent Form

Step 1 of 4

25%

Vitamin B12 Intake Form

Name:

Date

MM slash DD slash YYYY

Address

Street Address

Phone

Emergency Contact Name

Emergency Contact #

How did you hear about us?

Do you have or have you had any of the following conditions listed below in the past year/s?

Folic Acid Deficiency

Kidney / Liver Disease

Diabetes - Taking Metformin

Heart Condition

Pregnant / Breast Feeding

Epilepsy

Cancer/Chemotherapy

Anaemia / Low in Iron

Skin Problems

List of medications/herbal and/or nutritional supplements taken

Have you ever had an allergic reaction?

Other Conditions

List of medications

Allergic reaction?

Other Conditions

Have you got any known allergies especially to cyanocobalamin or cobalt?

Yes

Please list everything you are currently taking:

Prescription Medications – Strength – Frequency – Condition being treated

Over the Counter Drugs – Strength – Frequency – Condition being treated

Vitamins and Other Supplements – Strength – Frequency – Condition being treated

Vitamin B12 Consent Form

Vitamin B-12 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 since they go directly into the blood stream; however, there are alternative methods to B12 injections which are Oral Vitamins, B12 Patch, Lozenges, Liquid drops and Nasal Spray which have been explained fully to me.

B12 INJECTIONS COMMON SIDE EFFECTS INCLUDE BUT ARE NOT LIMITED TO

Diarrhea / Upset Stomach / Nausea
Mild bruising at the site of the injection
Slight Warmth at the site of the injection
Mild Joint / muscle ache
Mild headache

B12 INJECTIONS UNCOMMON AND DANGEROUS SIDE EFFECTS INCLUDE:

Rapid heartbeat
Chest pain and/or chest tightening
Flushed face, hives and/or skin rashes
Muscle cramps and weakness
Difficulty breathing, swallowing and/or shortness of breath
Dizziness and/or confusion
Rapid weight gain
Unusual wheezing and coughing

I agree to the terms and conditions of the service, including data processing and communications. I understand the policy and accept it.

1. If any unforeseen condition arises during the procedure that requires additional or alternative measures beyond what was originally planned, I authorize the provider to exercise their professional judgement and perform any actions they consider necessary for my safety and well-being.

2. There is a small risk of infection of the treated skin area after the procedure, although this is not expected to occur due to the sterility of the medical devices used. I have been informed that the highest standards of hygiene are met and that sterile disposable needles, equipment and PPE are used for each individual client.

3. I understand that a minimum of 6-8 weeks resting period is needed in between treatments unless stated otherwise by my provider.

4. I also understand and accept that I may require multiple treatments to achieve desired results due to the severity of my B12 deficiency and that 100% success cannot be guaranteed from the first procedure. I understand that this is why I may need to return for further treatment.

5. The result of the procedure is determined by the following: 1) Medication, 2) Herbal Products 3) Nutritional Supplements 4) Alcohol Intake 5) Smoking 6) Post procedure after care taken.

6. I understand that I need to avoid hot baths and showers, saunas, steam rooms and public pools for 48 hours post treatment.

7. I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for the payment of $35.00 at my appointment.

8. I understand that although side effects are a relatively rare occurrence, anyone taking vitamin B12 injections should be aware of the possibility that they could occur. Uncommon side effects are much more serious than the common side effects and if I experience such side effects, I will seek medical advice from my local pharmacy, doctor or ER Department.

By signing below, I acknowledge that I have read and fully understand the foregoing informed consent, and I agree to proceed with the treatment along with its associated risks. I hereby release the clinical team and overseeing physician, as well as Anastasija Medical Aesthetics, from any liability related to this procedure.

Signed in Ontario

Date

MM slash DD slash YYYY

Client Printed Name

Client Signature

Practitioner Printed Name

Practitioner Signature

PLEASE FOLLOW THE AFTERCARE ADVICE FOR INTRAMUSCULAR VITAMIN B12 INJECTION

You may experience some mild tenderness, redness and swelling around the injection site. These effects will usually resolve within 48 hours but may last longer in some cases.

You may experience some bruising around the injection site, this will resolve naturally but may take 1-2 weeks to resolve.

If you experience any discomfort afterwards you can take a simple over the counter painkiller such as Tylenol.

You must seek medical attention and contact your practitioner if you develop any signs or symptoms of skin infection around the injection site. Infection can present as hot, red shiny skin, there may be pus formation and you may have a fever or feel generally unwell.

You must contact your practitioner as soon as possible if you experience any other unwanted side effects after having the injection.

Seek medical attention if you feel unwell or experience any significant side effects following the injection.

Seek emergency medical attention in the rare event that you experience any severe allergy signs or features of anaphylaxis after the injection. These may include rash, facial swelling and breathing difficulties.

IT IS ESSENTIAL THAT YOU HAVE READ ALL OF THE INFORMATION AVAILABLE.

PLEASE DO LET YOUR PRACTITIONER KNOW IF YOU HAVE ANY QUESTIONS OR IF YOU DO NOT UNDERSTAND ANY OF THE AFTERCARE INSTRUCTIONS PROVIDED ABOVE.

Cancellation policy

Dear Patient/Client:

We strive to render excellent care to you and the rest of our patients and clients. Your care and treatment is a priority to us. We also ask that you respect your nurse injector’s time and expertise as well.

In an attempt to be consistent with this, we have a Medical Appointment Cancellation Policy that allows us to schedule appointments for our patients, with respect for your time, the next patient’s time, the nurse practitioner’s time, and the nurse injector’s time.

Our policy is as follows:

We request that you give 24 hours’ notice in the event that you cannot make it to your scheduled appointment. If a patient misses an appointment without contacting our office, it is considered a missed or “No Show” appointment. A fee as shown below will be charged to your credit card, depending on the type of appointment missed. Additionally, if a patient is more than 15 minutes late for an appointment, it will be considered a “no show” appointment, and that appointment will be rescheduled. Also, if you miss more than 3 appointments, Anastasija Medical Aesthetics reserves the right to discharge you from the practice for failing to follow treatment recommendations.

If you have any questions regarding this policy, please let our staff know, and we will be happy to clarify the policy for you.

We look forward to being a part of your continued wellness.

Terms

I have read and understand the Medical Appointment Cancellation Policy of Anastasija Medical Aesthetics, and I agree to be bound by its terms. I am aware that my credit card will be charged $50.00 for the missed appointment, and I agree to these terms.

Signature

Date

MM slash DD slash YYYY

Vitamin B12 Intake & Consent Form

Vitamin B12 Intake Form

Do you have or have you had any of the following conditions listed below in the past year/s?

Please list everything you are currently taking:

Vitamin B12 Consent Form

B12 INJECTIONS COMMON SIDE EFFECTS INCLUDE BUT ARE NOT LIMITED TO

B12 INJECTIONS UNCOMMON AND DANGEROUS SIDE EFFECTS INCLUDE:

PLEASE FOLLOW THE AFTERCARE ADVICE FOR INTRAMUSCULAR VITAMIN B12 INJECTION

IT IS ESSENTIAL THAT YOU HAVE READ ALL OF THE INFORMATION AVAILABLE.

PLEASE DO LET YOUR PRACTITIONER KNOW IF YOU HAVE ANY QUESTIONS OR IF YOU DO NOT UNDERSTAND ANY OF THE AFTERCARE INSTRUCTIONS PROVIDED ABOVE.

Cancellation policy

Dear Patient/Client:

Our policy is as follows:

Terms

All Rights Reserved. Copyright © 2025 Anastasija Medical Aesthetics