B12 Injections and MIC informed Consent

Vitamin B-12 and MIC helps maintain good health and has been shown to be beneficlal in helping to: Reduce stress, fatigue, improve memory and cardiovascular health, and maintain a a good body weight. It can also assist the body in converting proteins, fats and carbohydrates into energy and is necessary for healthy skin and eyes.

Bl2 Injections AND MIC are better absorbed by the body since they go directly ñto the blood stream. Alternatives to Bl2 injections are Oral Vitamins, Bl2 Patch, Lozenges, Liquid drops and Nasal Spray

Bl2 Injections and MIC common side effects include but are not limited to:

  1. Risks: I understand there is risk of id diarrhea, upset stomach, nausea, a feeling of pain and a warm sensation at thee 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 B12 and MIC injections can result in serious side effects. Although this is a relatively rare occurrence, anyone taking vitamin B12 and MIC injections should be aware of the possibility. Uncommon side effects are much more serious than the common side effects of Bl2 and MIC injections, and such side effects should be reported to a physician to be evaluated for seriousness. Uncommon and dangerous side effects include:
    • rapid heartbeat
    • chest pain
    • hushed face
    • muscle cramps and weakness
    • difficulty breathing and swallowing
    • diziiness
    • confusion
    • rapid weight gain
    • tight feelings in the chest
    • hives, skin rashes
    • shortness of breath when there 1s no physical exertion and unusual wheezing and coughing.
  4. Before starting vitamin B12 and MIC injections I will make sure to tell my PhysiCldo lfI am pregnant, lactating or have any of the following conditions.
    • Leber's Disease
    • Kidney disease
    • Liver disease
    • An infection
    • Iron deficiency
    • Folic acid deficiency
    • Receiving any treatment that has an effect on bone marrow
    • Taking any medication that has an effect on bone marrow
    • An allergy to cobalt or any other medication, vitamin, dye, food or preservative
  5. 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 B12 and MIC Inject:on.
  6. Treatments: Can be once a month, Once a week, Twice a week and 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 non- payment, 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 B12 and MIC Injections with the above understood. I hereby release the doctor, the person inject@g the B12, MIC, and the facility from liability associated with this procedure.