Consent for Intramuscular Injection(s)

Vitamin B12, Other Nutrient/Vitamin and Hormone Injections

I am requesting a nutrient and/pr hormone injection(s). These injections can contain B complex vitamins, amino acids, ,methionine, inositol, choline, chromium and lidocaine. The hormones that I may receive (if my doctor prescribes them) include testosterone and/or estradiol. These compounds are essential for proper functioning of the brain, liver, and nervous system, preventing and relieving the body fatigue, lowering
cholesterol levels, metabolizing fat and carbohydrates, suppressing appetite and food cravings. These injections can help boost weight loss.

I understand that these injections are either a nutrient/vitamin and/or hormone injections and as with all injections, may cause temporary redness, tenderness, bruising, or bleeding at the site of injection. I understand that possible side effects/risks include, but are not limited to: nausea, diarrhea, upset stomach, headache, joint and muscle pain, swelling, hives and vascular thrombosis. I acknowledge that no guarantee or assurance has been given by anyone as to the results which may be obtained.

I will inform the practitioner of any changes in my medical history, current medications, and/or any changes relevant to this procedure prior to any future treatments.

Vitamins, nutritional supplements and hormones are not intended to diagnose, treat, cure, or prevent any diseases or illnesses. NES strongly encourages all of our clients to develop a relationship with a Primary Care Provider and have regular check-ups. If at any time you develop any side effects or a medical emergency, please contact your Primary Care Provider, report to the nearest Emergency Department or Urgent Care Center, or Activate Emergency Medical Services by dialing 911.

I hereby give consent to receive this and all subsequent Vitamin and/or Hormone injections with the above understood. These substances that are used for injections have been explained to me and my questions regarding such treatment have been answered to my satisfaction. I understand the risks, benefits, possible side effects and complications of the injection.

By signing below, I CONFIRM THAT I DO NOT HAVE AN ALLERGY TO CHROMIUM, LIDOCAINE, AMINO ACIDS, VITAMIN B, TESTOSTERONE, or ESTRADIOL.

By signing below, I CONFIRM THAT I DO NOT HAVE LEBER’S DISEASE OR A LIVER OR KIDNEY IMPAIRMENT THAT I AM AWARE OF.