B12 consent form

By completing this Client Profile, you will assist us in evaluating you and your specific concerns. The information you will provide will be used to determine what factors may be affecting you so that we may recommend the proper treatment care.
If you answered (“Yes”) to any of the above questions 1-5, it may be advised by your practitioner that you not receive the injection and you may be denied services.
I have truthfully answered all questions regarding my medical history and have informed the staff about any and all prescription medications and/or over the counter drugs I take, as well as any street or recreational drugs. I understand that failing to inform the staff about my medical issues and/or drug use can lead to serious complications.