Contact Info

    General Vitamin Injections Informed Consent

    Client’s name Date

    Vitamins are vital for our body’s normal function and are absolutely necessary for our growth, general-well being, and vitality. Except for a few exceptions, vitamins cannot be manufactured or synthesized by the body and their absence or improper absorption results in specific deficiency diseases. Therefore it is important for our body to obtain vitamins from outside sources to battle against the chance for a deficiency. Latest researches indicate that many vitamins taken in large doses can have miraculous healing effects in a wide range of common complaints and illnesses. Proper vitamin injections can supply the much needed nutrients your body needs to maintain and enhance normal bodily functions.

    Vitamin Injections are better absorbed by the body since they go directly into the blood stream. Alternatives to these injections are Oral Vitamins, Capsules, Liquid drinks, Lotions, Topical Creams, and Mouth Sprays.

    Vitamin Injections common side effects include but are not limited to:

    1. Risks: I understand there is risk of mild diarrhea, upset stomach, nausea, a feeling of pain and a warm sensation at the site of the injection, a feeling, or a sense, of being swollen over the entire body, headache and joint pain.

    2. If any of these side effects become severe or troublesome I will contact my physician immediately.

    3. I understand that although rare Vitamin injections can result in serious side effects. Although this is a relatively rare occurrence, anyone taking Vitamin injections should be aware of the possibility. Uncommon side effects are much more serious than the common side effects of Vitamin injections, and such side effects should be reported to a physician to be evaluated for seriousness. Uncommon and dangerous side effects include:

    • headache
    • nausea
    • diarrhea
    • bloating
    • constipation
    • indigestion or heartburn
    • abnormal bleeding
    • gastrointestinal hyperactivity
    • chest pain
    • flushed face
    • chills
    • fever
    • upset stomach
    • kidney stones
    • fingernail weakening
    • hair loss
    • rapid heartbeat
    • heart palpitations
    • restlessness
    • muscle cramps and weakness
    • dizziness

    4. I understand the possibility of having an allergic reaction to any of the ingredients found within the Vitamin injection is quite plausible and that I should communicate with my Physician if I have any known allergic reactions to foods, dyes, preservatives, or any other substances. If I experience any of these following signs of allergic reactions I should immediately consult my primary health care Physician and discontinue further use of the product. Signs of allergic reactions include, but not limited to:

    • Itching of skin
    • Hives
    • Rashes
    • Wheezing
    • Difficulty breathing
    • Swelling of mouth or throat

    5. When medications are taken in conjunction with the Vitamin Injection, drug interactions could occur. These interactions can either increase your risk of bleeding or block the absorption of the Vitamins into the body. These medications at the time of your injection should either be discontinued or be consulted with by a Physician. Some of the
    medications that may cause drug interactions include, but are not limited to:

    • Heparin (Fragmin, Lovenox, Innohep…ect.)
    • Antithrombin (A Tryn, Thrombate III)
    • Argatroban
    • Aspirin
    • Ibuprofen
    • Dipyridamole (Persantine)
    • Bivalirudin (Angiomax)
    • Clopidogrel (Plavix)
    • Warfarin (Coumadin, Jantoven)
    • Nonsteroidal anti-inflammatory drugs (Ibuprofen,…etc.)

    6. Before starting the Vitamin injections I will make sure to tell my Physician if I am pregnant, lactating or have any of the following conditions.

    • Leber’s Disease
    • Kidney disease
    • History of Kidney stones
    • Liver disease
    • Hormonal disease
    • Cardiovascular disease
    • History of ulcers
    • History of gastrointestinal problems
    • Bipolar disorder (manic depression)
    • Attention Deficit Hyperactivity Disorder (ADHD)
    • Muscular Dystrophy
    • Elliptic seizures
    • Hypoglycemia
    • Schizophrenia
    • Benign prostatic hypertrophy (BPH)
    • Acetaminophen poisoning
    • Hypertension (high blood pressure)
    • History of seizures
    • Under-active thyroid (hypothyroidism)
    • Osteoporosis
    • Receiving treatment or taking any medication that might “thin” the blood
    • Receiving treatment or taking medication that has an effect on bone marrow
    • An infection
    • Iron deficiency
    • Folic acid deficiency
    • Dependent on intravenous nutrition (TPN) or liquid nutrition products for food
    • Diabetes, mellitus, or high blood sugar levels
    • An unusual or allergic reaction other medicines, foods, dyes, or preservatives

    7. I understand that certain herbal products, vitamins, minerals, nutritional supplements, prescription and non prescription medications may result in side effects when they interact with the Vitamin Injection.

    8. Treatments: Will be determined by the provider.

    I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I further agree in the event of nonpayment, to bear the cost of collection, and/or Court cost and reasonable legal fees, should this be required.

    By signing below, I acknowledge that I have read the foregoing informed consent and agree to the treatment with its associated risks. I hereby give consent to perform this and all subsequent Vitamin Injections with the above understood. I hereby release the doctor, the person injecting the Vitamin Injection, and the facility from liability associated with this procedure.