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Vitamin B12 Injection Informed Consent

Benefits of B12:

• More energy, mental alertness and stamina for everyday tasks

• Healthier immune systems

• Improves sleep

• Increased metabolism, thereby aiding in weight loss

• Reduces allergies, stress and depression

• Improves mood stabilization

• Lessens frequency and severity of migraines and headaches


• A vitamin B12 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 with-in forty-eight (48) hours.

• In rare cases, B12 can causes diarrhea, peripheral vascular thrombosis, itching, transitory exanthema, urticaria,feelings of swelling of the whole body.

• Drugs that decrease or reduce absorption of B12: antibiotics, cobalt irradiation, colchicine, colestipol, H2-blockers, metformin, nicotine, birth control pills, potassium chloride, proton pump inhibitors.


I have read this form and I consent to receive a B12 shots from the FORM By GBY staff now and in the future. I also understand that if I am a female and become pregnant or start breastfeeding in the future, it is my responsibility to make FORM staff aware of the change in status. I further realize that I cannot receive any B12 shots if I am pregnant or breastfeeding. I understand that the confidentiality of this information will be maintained in within legal limits.


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Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
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Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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