Veteran Owned and Operated

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Sheila L. Uridil, MSN, APRN, AGACNP-BC, ANP-BC
Joseph E. Uridil IV, MSN, APRN, AGACNP-BC
NeighborhoodHealthcareJ.S@gmail.com

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VITAMIN B12 INJECTION CONSENT FORM

PURPOSE OF TREATMENT
Vitamin B12 (cobalamin) injections are used to support B12 levels and may help with symptoms such as fatigue, weakness, or deficiency-related conditions. I understand that results may vary and are not guaranteed.

  • Energy & Fatigue: Converts food into energy, reducing tiredness and weakness.
  • Brain Health: Supports cognitive function, memory, mental clarity, and mood regulation.
  • Metabolism: Helps process fats and carbs, supporting weight management (when deficient).
  • Red Blood Cells: Essential for red blood cell production, preventing anemia.
  • Nervous System: Crucial for nerve health and can prevent neurological issues,.
  • Skin, Hair, Nails: Promotes cell regeneration, improving appearance.
  • Immunity: Supports immune system function.
  • Heart Health: Helps lower homocysteine levels, reducing heart disease risk.

WHO BENEFITS MOST

  • Individuals with diagnosed B12 deficiency (pernicious anemia, absorption issues).
  • Vegans or those with poor diets lacking B12.
  • Older adults, athletes, and people with absorption problems.

ONSET:

48-72 hours

MEDICAL DISCLOSURE
I certify that I have informed the provider of my complete medical history, including but not limited to:

  • Allergies (especially to cobalt or B12)
  • Pregnancy or breastfeeding status
  • Kidney disease, liver disease, or blood disorders
  • Current medications and supplements

RISKS & POSSIBLE SIDE EFFECTS
I understand that B12 injections are generally safe but may carry potential risks or side effects, including but not limited to:

  • Pain, redness, swelling, or bruising at the injection site
  • Headache, nausea, dizziness
  • Rash or itching
  • Rare allergic or anaphylactic reactions

I acknowledge that unforeseen side effects may occur.

ALTERNATIVES
I understand that alternatives to injectable B12 include oral or sublingual supplementation, dietary changes, or no treatment at all.

VOLUNTARY CONSENT
 I acknowledge that:

  • I have had the opportunity to ask questions, and all questions have been answered to my satisfaction.
  • I am not being coerced into receiving this treatment.
  • I may refuse or discontinue treatment at any time.

NO MEDICAL GUARANTEE
I understand that Vitamin B12 injections are not a cure for any disease and no guarantees have been made regarding outcomes or benefits.

RELEASE OF LIABILITY
I acknowledge I voluntarily assume all risks associated with receiving a Vitamin B12 injection and hereby release, waive, and hold harmless Neighborhood Healthcare, its medical providers, staff, and affiliates from any claims or liability arising from this treatment, except in cases of gross negligence. Prior to my injection, I will have the opportunity to discuss any concerns with the healthcare provider, and can request an electronic copy of this consent.

CONSENT
By signing below, I acknowledge that I have read, understand, and agree to this waiver and consent to receive a Vitamin B12 injection.

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