B12 Injections informed Consent
Vitamin B-12 helps maintain good health and has been shown to be beneficial 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.
B12 Injections are better absorbed by the body since they go directly into the blood stream. Alternatives to B12
injections are Oral Vitamins, B12 Patch, Lozenges, Liquid drops and Nasal Spray
B12 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 B12 injections can result in serious side effects. Although this is a
relatively rare occurrence, anyone taking vitamin B12 injections should be aware of the possibility. Uncommon
side effects are much more serious than the common side effects of B12 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
• flushed face
• muscle cramps and weakness
• difficulty breathing and swallowing
• rapid weight gain
• tight feelings in the chest
• hives, skin rashes
• shortness of breath when there is no physical exertion and unusual wheezing and coughing.
4. Before starting vitamin B12 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
• 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 Injection.
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 Injections with the above
understood. I hereby release the doctor, the person injecting the B12 and the facility from liability associated with
Patient Signature______________ Date: _________________________