VIVE WELLNESS
7950 S LINCOLN ST STE 111I,
LITTLETON, CO 80122
Lipotropic Injection Consent
What are Lipotropics Injections?
Lipotropic injections are used to help release fat deposits in some parts of the body. Some of these
areas include the stomach, inner thighs, neck, buttocks and hips. Lipotropic, or fat burning,
substances include methionine which helps the liver remove fat; inositol, similar to methionine;
choline, which distributes cholesterol and prevents it from getting deposited in one part of the body.
In some cases, a combination of these may be given. Injections can be administered up to twice a
week. B12 is purported by its users and practitioners to help speed up the overall metabolic
processes and create a greater feeling of overall energy. Because lipotropics directly aid fat
breakdown and are closely related to B vitamins, when used together they are thought to intensify
each others' effects. The amino acids stimulate the liver into optimizing the process of metabolism.
These injections boost the metabolic power of the body. The injections are only effective
temporarily. As soon as the effect of these substances wears out, the body starts returning to normal
gradually.
What Is In a Lipotropic Injection?
Vitamin B1 - Essential for glucose (sugar) metabolism.
Vitamin B2 - Breaks down protein, fats, and carbohydrates.
Vitamin B6 - Aids in the production of important neurotransmitters in the brain that help to limit food
cravings.
Vitamin B12 - Essential vitamin that helps form new healthy cells in the body. It acts as an energy
booster, helping increase activity level, improve sleep patterns and provide relief from allergies and
stress.
Methionine - An amino acid that contains sulfur. It helps prevent the buildup of excess fat in the liver.
Inositol - One of the nutrients that belongs to the B vitamin complex. It works to reduce blood
cholesterol and support the metabolism of fat.
Choline - Helps to transport fat and cholesterol, as well as help the liver eliminate chemical waste
products.
Your Partner In Weight Loss
Unlike other forms of weight loss treatments, lipotropic shots are non-invasive and they help
your body burn the fat naturally at an enhanced pace which means you’ll see weight loss
results fast. These shots are exceptionally effective for reducing fat in stubborn areas of the
body such as thighs, neck and buttocks. Lipotropic injections work best when received
regularly up to two (2) times weekly. We will work with you to determine and recommend an
injection schedule based on your needs.
Acknowledgement and Informed Consent
1. The nature and purpose of the injection, possible alternatives, risks involved and the possibility of
complications have been explained to me.
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VIVE WELLNESS
7950 S LINCOLN ST STE 111I,
LITTLETON, CO 80122
2. Each client responds differently and you may respond differently from one lipotropic injection to
the next. As with all supplements and medications the results are temporary and a regular dosing
schedule is necessary. No guarantee can be made with regard to the result or length of time it lasts.
3. I understand that although rare there is the possibility of side effects. I agree to contact my
Primary Care Provider, Emergency Department or Urgent Care if I experience any serious or
concerning side effects.
Although uncommon, potential side effects include: allergic reaction and/or anaphylaxis, headache,
nausea, diarrhea, bloating, constipation, indigestion or heartburn, abnormal bleeding, chest pain,
kidney stones, rapid heartbeat
4. I understand that there are some risks with any treatment. The following is the list of
possible risks with injection: pain or bruising of the skin injection site, scarring of the skin (unlikely),
and possible skin infection- a possibility any time the skin is broken, even with sterile needles.
5. I have been given the opportunity to have all of my questions answered.
Please carefully read and answer the following questions
Have you or has anyone in your family ever been
Yes
No
Yes
No
Yes
No
Yes
No
diagnosed with Leber's Disease or Leber Hereditary
Optic Neuropathy (LHON)? *
Are you currently receiving any treatment that has an
effect on bone marrow? *
Are you currently taking any medication that has an
effect on bone marrow? *
Female clients only: Are you currently pregnant or
breastfeeding?
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 and potential side effects. I hereby give consent to
perform this and all subsequent Lipotropic Injections with the above understood. I hereby
release Vive Wellness and its associated staff and/or contractors from liability associated
with this procedure.
Please sign and date :
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