Vitamin Injection Consent

(Telehealth or Brick-and-Mortar)

Date:

Patient Information

• Patient Name: {{patient_first_name}} {{patient_last_name}}
• Date of Birth: {{patient_birthdate}}

Allergy Information

Post-Injection Monitoring

It is recommended that you wait 20-30 minutes after your first injection to notice any potential side effects. Side effects, if any, might include:

Patient Authorization

I authorize my Provider to assist me in my wellness efforts. I understand it is my responsibility to follow all instructions carefully and report any significant medical problems that may be related to treatment (injection) as soon as reasonably possible.