B12 CONSENT

Wellness303 LLC

B12 Treatment Consent

2018

Vitamin B12 has been reported to naturally help with:

  • Increased Energy • Restored Mental Clarity • Boosts Immune System • Essential for Neurological Health • Essential for Red Blood Cell Function and Formation

Doctors know the health benefits of B12 and have treated patients who are feeling sluggish, tired, worn down or forgetful for years and have seen remarkable results. Regain the energy of your youth.

Free yourself from daily stress and anxiety. Live a happier, more productive life. Restore your mental clarity and avoid memory loss.

We offer B12 Treatment (shots) in several forms:

|Cyanocobalomin | Methylcobalomin | Amino | B-Complex |

RISK & POSSIBLE EFFECTS

  • B12 contains Cobalt and aluminum. Sensitivity to Cobalt, aluminum and/or other ingredients in  B12 is a contraindication.
  • Risk of allergic reaction, tenderness at injection site, infection at injection site as with all injections.
  • We do not treat or recommend  treatment to anyone under the age of 18 years old , or anyone with Leber’s Disease and/or Chronic Liver or Kidney Disease  unless a doctor’s note has been provided. If you have any questions, please ask NOW or ask your physician or Health Department before receiving. If you have a reaction, see your personal physician immediately.

By signing below you agree that; your personal information is accurate, I am in good health and/or I have my physician’s approval, I have read the above information about B12 Treatment, I have had the opportunity to ask my personal physician(s) questions regarding my receiving this shot and I understand the benefits and risks of this vitamin.

I, ___________________________, release Wellness303 LLC and any other organizations associated with the “B12 treatment”, and their agents, servants, successors, heirs, executors, administrators, landlord, lessor, and all other persons, firms, corporations, associations, or partnerships, affiliates, members, managers, officers, or directors, of and from any and all claims, actions, causes of action, demands, rights, damages, costs, loss of service, expenses and compensation whatsoever, which the undersigned now has/have or which may hereafter accrue on account of or in any way growing out of any and all known and unknown, foreseen and unforeseen bodily and personal injuries and property damage and the consequences thereof resulting or, to result from the “B12 Treatment” or in any connection with “B12 Treatment”. There is a $25.00 fee for all returned checks. A 50%(fifty-percent) fee will be added to the total balance due if this account is turned over to a third-party collection agency.

Client:___________________________
Signature: ________________________ Staff:___________________________

add e-signature plug in  sidenote: clause for age?? 18+

*too expensive ($300/year minimum). In bold near the click through button from this page we just need a blurb : “by clicking you agree that you have read and understand the information provided and had an opportunity to have my questions answered.

 

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