B12 Injection Consultation Form Name First Name Last Name Date of Birth Occupation Email Phone (###) ### #### Vitamin B12 injection is a treatment that delivers vitamin B12 directly into the bloodstream. Vitamin B12 is essential for various bodily functions, including nerve function, red blood cell production, and DNA synthesis. List any known medical conditions: Do you have any health problems? YES/NO - If your answer is "YES" please list them Are you currently taking any medications or supplements? If so, please specify: Have you ever had a B12 injection before? If yes, when was the last injection? If YES, when was the last injection? Have you experienced any allergic reactions to medications or injections in the past? If yes, please specify: If YES, when was the last injection? Contraindications: • Pernicious Anemia: A condition that impairs the absorption of vitamin B12 from food. • Allergy to Cobalt or Cyanocobalamin: Some individuals may be allergic to the forms of vitamin B12 used in injections. • Certain Medications: Inform us if you are taking medications that interact with vitamin B12, such as certain antibiotics or anticonvulsants. • A certain eye disease (Leber's optic neuropathy). • A certain blood disorder (polycythemia vera). • Hypokalemia. • Pregnancy. Contraindications: Discomfort and Side Effects: It's normal to experience mild discomfort, redness, or swelling at the injection site. These should subside within a few days. Hydration: Drink plenty of fluids to help your body process the vitamin B12. I confirm that the medical history is accurate and complete. Therefore, if there are any adverse effects due to an undisclosed medical condition, our therapists are absolved from any responsibility. I understand that withholding any medical information may be detrimental to my health and safety during which the practitioner agrees to undertake. It is my responsibility to advise my practitioner if there is any change in my medical history. Thank you for filling out the form!
