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THIS IS A MEDICAL FORM TO OBTAIN A PRESCRIPTION – IT IS YOUR RESPONSIBILITY TO READ IT THOROUGHLY

We will need to obtain your name, date of birth, phone number, valid mailing address, signature, and answers to all questions herein. Your personal information is protected in compliance with HIPAA laws and is not sold to third parties.

 

INFORMED CONSENT

I, or the person named herein for whom I am legally responsible, hereby request and voluntarily consent to receive IM Injection Therapy provided by licensed doctors or certified professionals under the doctor's supervision who are employees of B BAR™ and/or Thrivability™. 

 

I understand:

  1. The nutrients (e.g., vitamins, minerals, amino acids) and homeopathic medications that may be available to me are generally considered safe.
     
  2. It is my responsibility to disclose all health concerns, current conditions (including pregnancy), concurrent medications including supplements and over-the-counter drugs, any known allergies, and all previous adverse drug reactions I have experienced prior to treatment.
     
  3. All injectable solutions offered are administered by intramuscular injection, most commonly in the upper gluteal muscle (hip).
     
  4. The injectable solutions are sterile and have been supplied and/or compounded by an authorized compounding pharmacy located within the contiguous United States. They do NOT contain parabens or harmful ingredients or preservatives. 
     
  5. Side effects are generally non-existent or very mild and may include discomfort, bruising, redness of the skin, itching, muscle tightness, inflammation or pain at or around the injection site that could last from a few minutes to several days. Less frequent side effects may include irritated skin, nausea, diarrhea, pink or red colored urine, dizziness, headache, blurred vision, nervousness/anxiety, pounding in the ears, feeling of warmth or flushing, and slow or fast heartbeat. True allergic reaction is not common. Hypersensitivity side effects have rarely included anaphylactic reactions. Some adverse drug reactions are possible but not usual. Vasovagal reaction (a stress response) or syncope (fainting) can occur, especially if the recipient is dehydrated or has not had adequate food intake within two hours of the procedure.
  6. ​B BAR has the right to refuse treatment based on subjective and objective findings and assessment during the brief intake conducted prior to treatment including, but not limited to, inadequate nourishment within two hours of being seen.

  7. Immediate medical attention is necessary should I experience body rash, blurred vision, dizziness, nervousness, pounding in the ears, extremely slow or rapid heartbeat, difficult or labored breathing, difficulty swallowing, tightness in the chest, pain in the groin or lower legs, swelling or tingling of the hands and/or feet, severe generalized swelling, unusual weakness or fatigue, chest pain, or other symptoms not listed here.
     
  8. Most of the shot formulas contain methylcobalamin, hydroxocobalamin (injectable forms of B12) or both — there is no upper limit (UL) or toxicity associated with vitamin B12 supplementation.
     
  9. All B vitamins are water-soluble. Therefore, the body does not readily store them. The nutrients will typically stay in the system for up to 7 days. Most B vitamins have no possibility of toxicity with the exception of vitamin B3 (Niacin), vitamin B6 (Pyridoxine), and Folate (B9). These three B vitamins are generally considered safe even when double the recommended dose is taken. However, there are some vitamin-drug and vitamin-condition interactions that should be avoided. I am at liberty to discuss the risks and benefits with my personal physician prior to starting any new treatment or therapy, including B12 shots and nutrient injection therapy.
     
  10. The following medications have been shown to decrease the absorption of B12 and people taking any of these medications can benefit greatly from getting B12 shots. They include: colchicine (Colcrys); H2-blockers including Pepcid (famotidine), Tagamet (cimetidine), and Zantac (ranitidine); metformin; nicotine; birth control pills; potassium chloride; and proton pump inhibitors (PPIs) including Nexium (esomeprazole), Prevacid (lansprazole), Prilosec (omeprazole), Losec, Aciphex (rabeprazole), Pantaloc, and Zidovudine.
     
  11. If I am currently undergoing chemotherapy I will need to get written authorization from my oncologist before receiving any nutrient injection from B BAR.
     
  12. B12 is contraindicated in Leber's disease, a hereditary optic nerve atrophic condition, and may not be administered frequently in the presence of liver and/or kidney dysfunction. I will get approval from my personal physician prior to receiving a B12 shot if I have any of these conditions. 
     
  13. These statements have not been evaluated by the U.S. Food and Drug Administration (FDA). Shot formulas are proprietary and have not approved by the FDA to diagnose, treat or cure any disease condition, nor are they guaranteed to have any particular outcome. Individual results vary and cannot be guaranteed.
     
  14. Prices, formulas, solutions, locations, hours, and availability are subject to change without prior notification. 
     
  15. Fees for service are self-pay only and the terms of payment require full settlement before treatment. All shots are non-refundable and non-transferrable.
     
  16. I may not submit receipts to my insurance company or legal entity, including for MVA or PI cases, for reimbursement. Shots are not covered by insurance. 
     
  17. Injections are voluntary treatments and are not administered based on medical necessity.
     
  18. Use of my FSA (Flexible Spending Account) or HSA (Health Savings Account) card that has been issued by or through an insurance provider is at my own risk. It is my responsibility to get prior authorization from my FSA/HSA administrator before using these cards to pay for injection therapy including B12 shots. While the card will be processed and accepted as a credit card, the plan administrator may come back later and deny the charge(s) and take necessary action to charge the amount plus any associated fees back to me.

I Agree
to the following:

  • The procedure of Nutrient Injection Therapy (including B12 shots) has been adequately explained to me.
  • I have received all the information and explanation I desire concerning the procedure. All of my questions have been answered to my satisfaction.
  • This is a voluntary treatment and is not deemed medically necessary unless I have a physician's order or letter of medical necessity from my personal physician. It is not covered by insurance. 
  • I authorize and voluntarily consent to the procedure. 
  • I am not allergic to any injectable solution I am requesting and, to my knowledge, do not have a condition that could cause me to have an adverse reaction.
  • I do not have Leber's disease, liver disease, or compromised kidney function.
  • I have or will inform the doctor if I am or become pregnant or am currently breastfeeding.
  • I understand the possible complications of IM Injection Therapy and that side effects and risk may occur. Should a medical emergency arise, I agree to seek immediate treatment from an Emergency Department or call 911.
  • Neither myself, my heirs, assigns or legal representatives will sue or make any claims of any kind whatsoever against B BAR™, Thrivability™, Dr. Gayl Hyde, Naturopathic Doctor, PC, or any employees, heirs, successors, agents, partners, investors, associates, vendors, businesses or events providing space for treatments, including but not limited to Pharmaca Integrative Pharmacy, for any adverse reaction I may experience from receiving IM Injection Therapy, personal/bodily injury, property damage/loss, or wrongful death, whether caused by negligence or otherwise.
  • I intend for this Agreement to cover all subsequent visits for intramuscular (IM) injection therapy.
  • An electronic copy and/or photocopy of this agreement is considered to be as valid as an inked original, barring it has not been altered without prior consent.
  • I understand the information provided on this form and agree to its terms and the treatment I am requesting.
Please select who will be participating...
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First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Signature*
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Medical Overview
Please check all that apply: *
I have an allergy to ginkgo biloba +/or other botanicals
I am currently pregnant
I am currently breastfeeding
I currently have cancer
I am currently taking medication for a heart condition
I am currently undergoing chemotherapy
I am HIV positive
I have compromised kidney function
I have liver disease
NONE OF THE ABOVE
I am seeking treatment for the following reason(s). Please check all that apply: *
Wellness
Fatigue
Insomnia
Shingles
Weight Loss
Depression/Mood Enhancement
Menopause/Hormone Imbalance
Joint/Muscle Pain
Headache/Migraine
Anxiety/Nervousness
GI Upset
Acute cold or flu-like illness
Other
Do you have allergies to any medications?*
No
Yes

If you selected yes, please list all medications you are allergic to (e.g., penicillin, sulfa drugs, etc).
THE FOLLOWING SECTION IS ONLY FOR THOSE APPLYING FOR DISCOUNTED SHOTS THROUGH OUR NONPROFIT ORGANIZATION

Our sister registered 501(c)(3) nonprofit charitable organization, Thrivability™, offers discounted shots to those who are eligible. Eligibility is based on financial hardship, severe medical disability, and status as a veteran, active member of the military, fire or police department, as well as devout ethical vegans for no less than 6 months.

YES. I'd like to apply to receive discounted shots through your nonprofit organization.

IF YOU ANSWERED "YES" TO APPLY FOR DISCOUNTED SHOTS THROUGH OUR NONPROFIT, PLEASE CHECK ALL THAT APPLY TO YOUR UNIQUE SITUATION:

Financial Hardship (if selected, please answer questions 1 and 2 below)
Severe Medical Disability (if selected, please answer #3 below)
I am a veteran or an active member of the military, fire department, or police department. (ID required)
I am an ethical, devout vegan (for no less than 6 months)

ONLY ANSWER THE FOLLOWING 3 QUESTIONS AS THEY PERTAIN TO YOU TO BE CONSIDERED FOR OUR NONPROFIT ORGANIZATION.


1. How many people are in your household? (Only answer this if you are applying under financial hardship)

2. What is the annual income of your household? This includes all income for everyone living with you. (Only answer this if you are applying under financial hardship)

3. If you have a severe medical disability, please describe.
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.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
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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