Wellness Injection Informed Consent Agreement-Top Beauty Bar

Each patient responds differently to medicine and may respond differently from one treatment to the next. As with all medicines, either oral or injectable, results are temporary and regular dosing is necessary. The length of time the injectable medication lasts varies in each patient. No guarantee can be made regarding the results and length of time it lasts. Weight loss can be inconsistent from one week to the next. 

As with any treatment there can be some risk. The following is the list of possible risks with injections: Pain or bruising, mild burning, redness, bleeding at the injection site (these are usually minimal and dissipate in minimal amount of time). Some people may experience allergic reactions to the injections. Stomach upset and urinary problems (urge incontinence), diarrhea.

Please let us know if you have any of the following:

Kidney disease • Liver disease • An active infection • Iron deficiency • Folic acid deficiency • Receiving any treatment that influences bone marrow. • Taking any medication that influences bone marrow • An allergy to cobalt or any other medication, vitamin, dye, food or preservative. 

Vitamins are vital for our body’s normal function and are 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. Proper vitamin injections can supply the much-needed nutrients your body needs to maintain and enhance normal bodily functions.

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

1. Risks: I understand there is risk of mild diarrhea, upset stomach, nausea, a feeling of pain and a warm sensation at the site of the injection, a feeling, or a sense, of being swollen over the entire body, headache, and joint pain.

2. If any of these side effects become severe or troublesome, I will contact my physician immediately.

3. I understand that although rare Vitamin injections can result in serious side effects. Although this is a relatively rare occurrence, anyone taking Vitamin injections should be aware of the possibility. Uncommon side effects are much more serious than the common side effects of Vitamin injections, and such side effects should be reported to a physician to be evaluated for seriousness. Uncommon and dangerous side effects include: headache, nausea, diarrhea, bloating, constipation, indigestion, heartburn, abnormal bleeding, gastrointestinal hyperactivity, chest pain, flushed face, chills, fever, upset stomach, kidney stones, fingernail weakening, hair loss, rapid heartbeat, heart palpitations, restlessness, muscle cramps, weakness, dizziness.

4. I understand the possibility of having an allergic reaction to any of the ingredients found within the Vitamin injection is possible and that I should communicate with my Physician if I have any known allergic reactions to foods, dyes, preservatives, or any other substances. If I experience any of these following signs of allergic reactions, I should immediately consult my primary health care Physician and discontinue further use of the product. Signs of allergic reactions include, but not limited to: Itching of skin, Hives, Rashes, Wheezing, Difficulty breathing, Swelling of mouth or throat.

5. 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 or be consulted with by a Physician. Some of the medications that may cause drug interactions include, but are not limited to: Heparin, Fragmin, Lovenox, Antithrombin (A Tryn, Thrombate III), Argatroban, Aspirin, Ibuprofen, Dipyridamole (Persantine), Bivalirudin (Angiomax), Clopidogrel (Plavix), Warfarin (Coumadin, Jantoven), Nonsteroidal anti-inflammatory drugs (Ibuprofen,…etc.)

6. Before starting the Vitamin injections I will make sure to tell my Physician 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, Elliptic seizures, Hypoglycemia, 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, Folic acid deficiency, Dependent on intravenous nutrition (TPN) or liquid nutrition products for food, Diabetes, mellitus, or high blood sugar levels, An unusual or allergic reaction other medicines, foods, dyes, or preservatives.

7. I understand that certain herbal products, vitamins, minerals, nutritional supplements, prescription and nonprescription medications may result in side effects when they interact with the Vitamin Injection.

8. Treatments: Will be determined by the provider. This injection contains ascorbic acid, B1, B2, B3, B5, B6, B12, potassium, methionine, inositol, choline, and lidocaine.

9. It is my responsibility to inform the provider if I am allergic to any of the above substances.

10. This type of medication is from a compounding pharmacy and therefore, is not approved by the FDA.

11. The information I give the provider and nursing staff is accurate and complete to the best of my knowledge. Any changes to my medical history will be communicated to a TOP BEAUTY BAR provider immediately.

12. I am a legal adult 18 years of age or older and I am fully competent to make my own health care decisions. I am fully aware of potential side effects and/or problems associated with this medication and understand that it is a violation of the law to falsify any information on my medical questionnaire or other medical records for the purpose of obtaining prescription medication.

I have read, and acknowledge these requirements of the procedure.