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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.

Medical Services Provided by Primary Medical of KY, P.S.C., Elite Health Services, P.A., CO., Primary Medical of IN, P.C. 2025.04.21

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December 13, 2025 1:56 pm EDT

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