Vitamin Injection Consultation Form || Lilys Beauty & Aesthetic

Date

Client Name

Tel. No.

Email

Treatment Being Received:

B12

Vitamin C

Vitamin B Complex

Biotin

Vitamin D

Hay Fever

Other

Have you received this treatment before ? (if yes did the treatment meet your needs and expectations?)

What are your main reasons for having the treatment with us today please select yes or no

Fatigue

Low Mood

Pernicious Anemia

Weight Loss

Irritability

Improve Immunity

Decrease Symptoms of Hay Fever

Poor Sleep

Headaches

Increase Metabolism

Other

Please check if you have any of the following:

Fatigue

Low Depressed Mood

Pernicious Anemia

Taking Antibiotics

Irritability/moodiness

Pregnant/trying to be pregnant

Heart Disease

Diabetes

Memory Loss/Alzheimer's

Sleep Disorders

Osteoporosis

Tendonitis

Asthma

Allergies

Immunosuppression

Thyroid Disorders

IBS/Inflammatory Bowels

Numbness or tingling of body

Have You received any injectable treatments within the last 4 weeks? (if you have stated "yes" please list the injectable treatments, you haave had within the last 4 weeks.)

Describe your tolerance to needles?

If you have a select low tolerance, please explain more about any fear you may have?

Do you have a known allergies to any injected medications, vitamins or supplements?

i have read the information regarding risks and benefits of vitamin injections give to me by my practitioner and have had a chance to ask questions on the treatment. I understand the possible complications of injection therapy are minor brusing and bleeding at injected sites, dizziness, Headaches and possible fainting from the site of blood. I understand clearly that there may be a slight chance for sensitivities and reactions to the vitamin solution. I hereby relese from all liabilities regarding my treatment with B12 injections.

Client Name

Do you have any concerns or additional questions?

Possible Side Effects and Contraindications from Vitamin Injections

A vitamin shot is safe and generally has no side effects, even in higher doses.
Some redness and swelling at the injection site may occur. This should start to get better within forty eight (48) hours.
In rare cases, vitamin shots can cause diarrhoea, peripheral vascular thrombosis, itching, transitory exanthema, urticaria, feelings of swelling of the whole body.
Sensitivity to cobalt and/or cobalamin is a contraindication.
People with chronic liver and/or kidney dysfunction should not take vitamin injections
Interactions with drugs: antibiotics, cobalt irradiation, colchicine, colestipol, H2-blockers, metformin, nicotine, potassium chloride, proton pump inhibitors such as Prevacid, Losec, Aciphex, Pantaloc, and Zidovudine.

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