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.
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.
- 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).
- 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.
- All injectable solutions offered are administered by intramuscular (IM) injection, most commonly in the gluteus medius muscle (hip).
- 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.
- 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.
I may be refused treatment based on individual assessment and objective findings during the intake conducted and information shared on this consent form.
- 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.
- All shot formulas contain cobalamin (vitamin B12); there is no upper limit (UL) or toxicity associated with vitamin B12 supplementation.
- 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.
- 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.
- 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.
- Prices, formulas, solutions, locations, hours, and availability are subject to change without prior notification.
- Fees for service are self-pay only. Full settlement is required before treatment. Payments are non-refundable and non-transferrable.
- Injections are voluntary treatments and are not administered based on medical necessity.
- 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.
- 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.