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B-12 injection and/or IV Vitamin Infusion Informed Consent

Before Receiving a Vitamin B12/ MIC/ or Glutathione Injectable Treatment: 
Avoid medications that inhibit clotting such as vitamin E, aspirin, or non-steroidal anti-inflammatory drugs for seven days prior to treatment.

 

During a Vitamin B12/ MIC/ or Glutathione Injectable Treatment:
You will feel a small needle injection and a slight stinging sensation, which will last about 3-5 seconds.

 

After Vitamin B12/ MIC/ or Glutathione Injectable Treatment:

·      Ice may be used for any discomfort but usually none is required.

·      Bruising/swelling at injection site may occur.

Possible side effects of Vitamin B12/ MIC/ or Glutathione Injectable Treatment:

After Vitamin B12/ MIC/ or Glutathione Injectable Treatment

·      Possible upset stomach

·      Possible diarrhea

·      Possible increase/decrease in energy

·      Possible joint pain

·      Possible cutaneous skin reactions

 

Vitamin B12/ MIC/ or Glutathione are nutrient compounds that have proven effective in providing overall health, energy as well as weight loss when combined with a balanced diet and exercise program.

Benefits of Vitamin B12/ MIC/ or Glutathione injections:

Lipotropic nutrients are compounds that help catalyze the breakdown of fat during metabolism. They help promote the flow of fat & bile to and from the liver. In essence, they promote improved liver function and fat metabolism. The injection can prevent excess fat buildup in the liver - preventing fatigue. Vitamin B12/ MIC/ or Glutathione can decrease resistant fat deposits, boost energy, transform carbohydrates into even more energy, accelerates thought process, helps keep healthy skin tone and strong nails, promotes healthy hair growth, controls estrogen levels, helps control cholesterol levels and gallstones, improves mood, speeds up metabolism and the natural removal of fat in a time released formula.

Vitamin B12/ MIC/ or Glutathione Ingredients:

Methionine: Methionine is one of the sulfur-containing amino acids and is important for many bodily functions. It acts as a lipotropic agent to prevent excess fat buildup in the liver and the body, is helpful in relieving or preventing fatigue, and may be useful in some cases of allergy because it reduces histamine release. Methionine works as an antioxidant (free radical deactivator) through conversion to L-cysteine to help neutralize toxins.

Inositol: is a nutrient belonging to the B vitamin complex that aids in the metabolism of fats and helps reduce blood cholesterol. Inositol also participates in the action of serotonin, a neurotransmitter known to control mood and appetite.

Choline: is considered one of the B-Complex vitamins as well as a lipotropic nutrient. It is present in the body of all living cells and functions in conjunction with inositol as a basic constituent of lecithin. Choline appears to be associated with the utilization of fats and cholesterol in the body. It helps prevent fat from accumulating in the liver and encourages the movement of fats into the cells.

Cyanocobalamin, Vitamin B-12: is involved in metabolism and energy production. It works synergistically with the other lipotropic agents to help metabolize fat.

Glutathione: is a natural liver enzyme that the liver needs for breaking down toxins. With multiple treatments, skin glutathione can make your skin brighter and clearer. You may also experience increase in energy and immune system boosting from this treatment due to the detoxification effects.

CONSENT: By signing below I acknowledge that I have read the foregoing; informed consent and agreed to the treatment. I hereby give consent to perform this and all subsequent Vitamin B12/ MIC/ or Glutathione injections with the above understood.

I hereby request and authorize Lüz Lounge to perform the following procedure – Vitamin B12/ MIC/ or Glutathione Injections. It has been explained to me the potential risks involved. I agree to fulfill the aftercare instructions noted above to help reduce these possible effects and optimize the effectiveness of the treatment.

I am aware the use of Vitamin B12/ MIC/Glutathione for energy or weight loss is considered “off label” and is not approved by the FDA. I therefore authorize Lüz Lounge personnel to perform the requested procedures. I understand the pre and post-treatment protocol and accept the risks to undergo this procedure. Any questions I may have been answered satisfactorily.

My signature certifies, I do understand the goals, limitations, alternative treatments, and possible complications of Vitamin B12/ MIC/ or Glutathione Injections.I voluntarily wish to proceed with the procedure. The procedure has been explained to me. I have read the above and understand it. My questions have been answered satisfactorily.

I understand the information on this form is essential to determine my medical and cosmetic needs and the provision of treatment. I understand that if any changes occur in my medical history/health I will report it to the office as soon as possible. I have read and understand the above medical questionnaire. I acknowledge that all answers have been recorded truthfully and will not hold any staff member responsible for any errors or omissions that I have made in the completion of this form.


 April 21, 2024



First Client's Name

First Name*

Last Name*
First Client's Age Acknowledgment*
First Client's Date of Birth*
I certify that I am 18 years of age or older
First Client's Information
I certify that I have never been diagnosed or have been treated for: Congestive Heart Failure, Renal Insufficiency, Neurological Disorders, Encephalopathy.*
No
Yes

Any allergies to medications or food?
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information
I certify that I have never been diagnosed or have been treated for: Congestive Heart Failure, Renal Insufficiency, Neurological Disorders, Encephalopathy.*
No
Yes

Any allergies to medications or food?
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information
I certify that I have never been diagnosed or have been treated for: Congestive Heart Failure, Renal Insufficiency, Neurological Disorders, Encephalopathy.*
No
Yes

Any allergies to medications or food?
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information
I certify that I have never been diagnosed or have been treated for: Congestive Heart Failure, Renal Insufficiency, Neurological Disorders, Encephalopathy.*
No
Yes

Any allergies to medications or food?
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information
I certify that I have never been diagnosed or have been treated for: Congestive Heart Failure, Renal Insufficiency, Neurological Disorders, Encephalopathy.*
No
Yes

Any allergies to medications or food?
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information
I certify that I have never been diagnosed or have been treated for: Congestive Heart Failure, Renal Insufficiency, Neurological Disorders, Encephalopathy.*
No
Yes

Any allergies to medications or food?
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information
I certify that I have never been diagnosed or have been treated for: Congestive Heart Failure, Renal Insufficiency, Neurological Disorders, Encephalopathy.*
No
Yes

Any allergies to medications or food?
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information
I certify that I have never been diagnosed or have been treated for: Congestive Heart Failure, Renal Insufficiency, Neurological Disorders, Encephalopathy.*
No
Yes

Any allergies to medications or food?
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information
I certify that I have never been diagnosed or have been treated for: Congestive Heart Failure, Renal Insufficiency, Neurological Disorders, Encephalopathy.*
No
Yes

Any allergies to medications or food?
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information
I certify that I have never been diagnosed or have been treated for: Congestive Heart Failure, Renal Insufficiency, Neurological Disorders, Encephalopathy.*
No
Yes

Any allergies to medications or food?
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
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.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
I certify that I have never been diagnosed or have been treated for: Congestive Heart Failure, Renal Insufficiency, Neurological Disorders, Encephalopathy.*
No
Yes

Any allergies to medications or food?
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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