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

We 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 shared with third parties other than those directly related to your treatments, namely the compounding pharmacies we use to obtain your prescriptions.

You will need to show a valid photo ID that displays your birthdate, such as a drivers license, to confirm your identity prior to your first treatment.

 

  WE DO NOT ADMINISTER SHOTS TO THOSE WHO ARE CURRENTLY PREGNANT, BREASTFEEDING, BEING TREATED FOR CANCER OR HAVE KIDNEY DISEASE. 

  B12 SHOTS ARE CONTRAINDICATED IN THOSE WITH LEBER'S DISEASE AND HYPOKALEMIA.  

 

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 B BAR® or Thrivability™ and administered by a licensed doctor or qualified professional under the licensed doctor's supervision.

 

I understand:

  1. The nutrients (e.g., vitamins, minerals, amino acids) and biological homeopathic preparations available to me are generally considered safe. However, these solutions cross the placenta and are distributed into breast milk and should be avoided during pregnancy or while breastfeeding unless ordered by my treating physician. Vitamin B12 is to be avoided in those with hypokalemia (potassium defieicncy) and Leber’s disease (hereditary optic nerve atrophy). 
     
  2. It is my responsibility to disclose all health concerns, current conditions (including pregnancy and breastfeeding), 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 (IM) injection, most commonly in the gluteus medius muscle (hip).
     
  4. The compounded injectable nutrients are sterile and have been prepared by an authorized compounding pharmacy located within the contiguous United States. They do NOT contain parabens or harmful ingredients or preservatives. However, they do contain benzyl alcohol, which should be avoided in the presence of a known allergy to benzyl alcohol and when breastfeeding, as it has been associated with toxicity, metabolic acidosis and death in neonates (infants less than 4 weeks old) and low-birth weight infants.
     
  5. Side effects are generally non-existent or 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, transient elevations in blood pressure, and slow or fast heartbeat. Some adverse drug reactions are possible but not usual. Vasovagal reaction (a stress response) or syncope (fainting) can occur, especially if the recipient is extremely nervous about receiving a shot, is severely dehydrated or has not had adequate food intake within two hours of the procedure. Allergic reaction is rare but may include anaphylaxis, chest tightness, edema (swelling), urticaria (hives), pruritus (itching), dyspnea (difficult or labored breathing), and rash.
  6. ​I may be refused treatment based on individual assessment and objective findings during the intake conducted and information shared on this consent form. 

  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. All shot formulas contain cobalamin (vitamin B12); there is no upper limit (UL) or toxicity associated with vitamin B12 supplementation.
     
  9. All nutrients available to me are water-soluble, meaning the body does not readily store them. The nutrients will typically stay in circulation for up to 7 days, give or take, depending on the individual's health and lifestyle factors. 
     
  10. If I am currently undergoing chemotherapy or receiving medical treatments for cancer I will need to get written authorization from my oncologist before receiving any nutrient injections.
     
  11. Statements made regarding nutrient injection therapy have not been evaluated by the U.S. Food and Drug Administration (FDA). Shot formulas are intended as supplementation for generally well adults; they have not been approved by the FDA to diagnose, treat or cure disease, nor are they guaranteed to have any particular outcome. Individual results vary and cannot be guaranteed.
     
  12. Prices, formulas, solutions, locations, hours, and availability are subject to change without prior notification. 
     
  13. Fees for service are self-pay only. Full settlement is required before treatment. Payments are non-refundable and non-transferrable.
     
  14. Injections are voluntary treatments and are not administered based on medical necessity.
     
  15. I may not submit receipts to my insurance company or legal entity, including for MVA (motor vehicle accidents) or PI (personal injury) cases, for reimbursement. Shots are not covered by insurance.
     
  16. 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 deny the charge(s) at a later date and take necessary action to charge the amount plus any associated fees back to me. B Bar® does not provide coded receipts or letters of medical necessity. 

I Agree
to the following:

  • The procedure of Nutrient Injection Therapy has been adequately explained to me.
  • I have received all the information and explanation I desire concerning the procedure.
  • 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 and I will not seek insurance reimbursement.
  • I authorize and voluntarily consent to the procedure. 
  • To my knowledge I am not allergic to any injectable solution I am requesting, including benzyl alcohol, and do not have a health condition that could cause me to have an adverse reaction.
  • I have or will inform the doctor if I am or become pregnant, begin breastfeeding, or am diagnosed with cancer or other immunocompromised condition.
  • 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.
Gender
Please select from the following options*
Medical Overview
Please check all that apply: *
I have an allergy to ginkgo biloba, calendula, chamomile, comfrey, cohosh, echinacea, arnica, bellis perennis (daisy), ginseng, witch-hazel, St. John's wort, yarrow, yellow jasmine, tomato plants or any other botanical/herb not listed here
I am currently pregnant or breastfeeding
I currently have cancer
I am HIV positive
I have kidney disease
I have liver disease
I have Leber's disease (hereditary optic nerve atrophy)
I have hypokalemia (potassium deficiency)
I have heart block (I need or have a pacemaker)
NONE OF THE ABOVE
I am seeking treatment for the following reason(s). Please check all that apply: *
Wellness (this is common)
Fatigue
Insomnia
Shingles
Weight Loss
Depression/Mood Enhancement
Menopause/Hormone Imbalance
Joint/Muscle Pain
Headache/Migraine
Anxiety/Nervousness
GI disorder or upset
Acute cold or flu-like illness
Cleanse/Detox
Other
Do you have allergies to any MEDICATIONS?*

If you selected yes, please list all medications you are allergic to (e.g., penicillin, sulfa drugs, etc).
How did you hear about us?
I heard about B BAR® from:*

If you chose client, medical professional, or Pharmaca employee above, please let us know the name of the person who referred you so we can thank them!
Do you want to receive discounted shots through our charitable organization?

Please select one of the following if you're interested in receiving discounts on your (B) shots. Thrivability is a registered 501(c)(3) nonprofit charitable organization. You will need to complete the charitable eligibility form found on our website or available in person. Please let us know that you would like to receive discounted shots thorough our nonprofit organization. Thank you. 

I'M NOT INTERESTED/ELIGIBLE FOR CHARITABLE SHOTS
Yes, sign me up; I am a first responder
Yes, sign me up; I am in the military or a veteran
Yes, sign me up; I am financially challenged
Yes, sign me up; I am medically disabled
Yes, sign me up; I am the caregiver of a family member in a hospice program or who's medically disabled
Yes, sign me up; I am a devout, ethical vegan
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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