Consent Form

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Client's Name
Date / Time

Vitamins are vital for our body’s normal function and are absolutely necessary for our growth, general-well being, and vitality. Except for a few exceptions, vitamins cannot be manufactured or synthesized by the body and their absence or improper absorption results in specific deficiency diseases. Therefore it is important for our body to obtain vitamins from outside sources to battle against the chance for a deficiency. Latest researches indicate that many vitamins taken in large doses can have miraculous healing effects in a wide range of common complaints and illnesses. Proper vitamin injections can supply the much needed nutrients your body needs to maintain and enhance normal bodily functions.

Vitamin Injections are better absorbed by the body since they go directly into the blood stream. Alternatives to these injections are Oral Vitamins, Capsules, Liquid drinks, Lotions, Topical Creams, and Mouth Sprays.

Vitamin Injections common side effects include but are not limited to:

  1. Risks: I understand there is risk of mild diarrhoea, upset stomach, nausea, a feeling of pain and a warm sensation at the site of the injection.
  2. If any of these side effects become more troublesome I will contact my G.P. immediately.
  3. I understand that although rare, Vitamin injections can result in other side effects. Although this is a relatively rare occurrence, anyone taking Vitamin injections should be aware of the possibility. Uncommon side effects are more serious than the common side effects of Vitamin injections, and such side effects should be reported to a GP. Uncommon side effects include:
  • indigestion or heartburn
  • abnormal bleeding
  • gastrointestinal hyperactivity
  • chest pain
  • chills
  • fever
  • kidney stones
  • fingernail weakening
  • hair loss
  • rapid heartbeat
  • heart palpitations
  • Restlessness
  • muscle cramps and weakness
  1. I understand the possibility of having an allergic reaction to any of the ingredients found within the Vitamin injection, although rare, may occur. I confirm that I will contact my GP should I have any unusual health concerns. Communication with my Practitioner about any allergic reactions may obviate any rare side effects.i.e. reactions to foods, dyes, preservatives, or any other substances.

Signs of allergic reactions include, but not limited to:

  • Itching of skin
  • Hives
  • Rashes
  • Wheezing
  • Difficulty breathing
  • Swelling of mouth or throat
  1. When medications are taken in conjunction with the Vitamin Injection, drug interactions could occur. These interactions can either increase your risk of bleeding or block the absorption of the Vitamins into the body. These medications at the time of your injection should either be discontinued for that day, or if essential, taken earlier or later than the injection.  Some of the medications that may cause drug interactions include, but are not limited to:
  • Heparin (Fragmin, Lovenox, Innohep…ect.)
  • Antithrombin (A Tryn, Thrombate III)
  • Argatroban
  • Aspirin
  • Ibuprofen
  • Dipyridamole (Persantine)
  • Bivalirudin (Angiomax)
  • Clopidogrel (Plavix)
  • Warfarin (Coumadin, Jantoven)
  • Nonsteroidal anti-inflammatory drugs (Ibuprofen,…etc.)
  1. Before starting the Vitamin injections I will ensure to discuss with my Practitioner if I am pregnant, lactating or have any of the following conditions:
  • Leber’s Disease
  • Kidney disease
  • History of Kidney stones
  • Liver disease
  • Hormonal disease
  • Cardiovascular disease
  • History of ulcers
  • History of gastrointestinal problems
  • Bipolar disorder (manic depression)
  • Attention Deficit Hyperactivity Disorder (ADHD)
  • Muscular Dystrophy
  • Schizophrenia
  • Benign prostatic hypertrophy (BPH)
  • Acetaminophen poisoning
  • Hypertension (high blood pressure)
  • History of seizures
  • Under-active thyroid (hypothyroidism)
  • Osteoporosis
  • Receiving treatment or taking any medication that might “thin” the blood
  • Receiving treatment or taking medication that has an effect on bone marrow
  • An infection
  • Iron deficiency
  • Dependent on intravenous nutrition (TPN) or liquid nutrition products for food
  • An unusual or allergic reaction to, other medicines, foods, dyes, or preservatives
  1. I understand that certain herbal products, vitamins, minerals, nutritional supplements,  and non prescription medications may result in side effects when they interact with the Vitamin Injection.
  2. Treatments, frequency and timings, wiill be determined by the provider in consultation with myself.