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
Important: Any member with an allergy to sulfa or red dye cannot receive this shot, and should look for another option. Also included in a Buck Shot are:
Anyone with an allergy to red dye cannot receive this shot.
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.
