B Complex Shot Consent & Release Form:
Name: _________________________________________________________________
Phone: _______________________
Address: ________________________________________________________________ E-mail: ____________________________________
Date of birth: ______/______/______ Age: _____
Sex: Male Female
In case of emergency: _________________________________________ Phone: __________________
Do you have Leber’s Disease?
Are you currently pregnant or breastfeeding? Yes
I request treatment with B12 or MIC-B12. The injection of B12 and MICB12 has 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 understand the recommended does for B complex 2ML intramuscular weekly, bi-weekly, or monthly
Possible side effects can include irritation at the site, infection, bruising, and tenderness at the injection site.
I certify that I do not have an allergy to sulfa or cobalt.
I certify that I do not have a liver or kidney impairment that I am aware of or any of the other contraindications listed. People with this condition should
not have b12 injections
Niacin (B3) can cause flushing and redness. Consuming Alcohol along with niacin might make the itching and flushing worse. Taking niacin and
using a nicotine patch can increase the chance of itching and flushing.
Interactions with drugs: Anticholinergic drugs ( bronchodialators) interact with riboflavin, statins ( cholesterol lowering) interact with niacin,
chlorphenicol (antibiotic) can impede on the red blood cell producing effects of B12 Amiodarone (for ventricular arrhythmias) interacts with B6
Other drugs that can decrease or reduce the absorption of b12: antibiotics, cobalt irradiation, chlorphenicol, colestipol, [email protected] blockers, metformin,
nicotine, birth control pills, potassium chloride, proton pump inhibitors such as Prevacid, Losec, Aciphex, Pantaloc and Zidvovudine
Reason you are interested in receiving the B Complex ______________________________________________________________________
Circle if you have any of the following:
Low depressed mood
Pernicious Anemia Weight issues
Pregnant/trying to become pregnant
Sleep disorders
Breast feeding
Thyroid disorders
Heart Disease
IBS/Inflammatory Bowels
Memory loss/Alzheimer’s
History of Migraines
Numbness/tingling of body
Pertinent medical/family history:________________________________________________________________________________
Current medications/dosing including over the counter and vitamin supplements:
Medication allergies: ______________________________Have you ever had any adverse reaction to a vitamin or an injection? Y N
Before this and EVERY injection I will inform epic MedSpa staff if I have any of the following
circle all that apply
Lebers Disease
Kidney Disease
Liver Disease
Any infection
Talking methotrexate
Cobalt/Sulfa allergy
Polycythemia Vera (blood disorder)
Iron deficiency
History of Gout
I certify that I am in good health and/or have my physician’s approval. I have read the above information about the B-Complex injection. I have the
opportunity to ask my personal physician’s questions that I may have had before receiving this injection. I understand the benefits and risks regarding this
injection. I release epic Medspa, their doctors, and employees, directors, from any and all liability arising from or in connection with this injection.
Vitamin b complex is safe and non-toxic even when taken in high doses, however I understand that it is possible that I could have an adverse reaction,
though rare they can include: mild diarrhea, anxiety/panic attacks, heart palpitations, insomnia, breathing problems, chest pain, skin rashes/hives.
Most common side effects are redness/swelling and soreness around the injection site lasting up to a few days.
We do not offer Acute/Urgent Care Services nor do we offer Primary Care Provider Services. We strongly recommend all of our clients to form a
relationship with a Primary Care Provider and have regular check-ups. If at any time you are faced with 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. Vitamins and
nutritional supplements are not intended to diagnose, treat, cure, or prevent any diseases or illnesses.
Name:__________________________________ Signature________________________________ Date:______________

B Complex Pre-Injection Consent Form