Form Vitamin Injection Consent Patient Information First Name Middle Name Last Name Birthdate Email Address City State Zip Phone Any Allergies? Current Medical Issues Emergency Contact Name Relationship Phone Liability Waiver I acknowledge that I have received a copy of Radiant Recharge LLC's HIPAA Privacy Notice. I acknowledge that I have voluntarily chosen to receive a vitamin injection. I understand that the injection will be administered by a qualified professional, but there are inherent risks associated with any medical procedure, including but not limited to, bruising, swelling, infection, and allergic reactions.I understand that the purpose of the vitamin injection is to supplement my diet with essential vitamins and minerals, and it is not intended to diagnose, treat, cure, or prevent any disease. I acknowledge that I have been advised to consult with a healthcare provider before undergoing this procedure, especially if I have any pre-existing medical conditions or concerns.I understand that the effects of the vitamin injection may vary from person to person, and there is no guarantee of specific results. I agree to follow any post-injection instructions provided by the administering professional and to report any adverse reactions or concerns immediately.In consideration of being allowed to receive the vitamin injection, I hereby release, discharge, and hold harmless Radiant Recharge, its employees, agents, and affiliates, from any and all claims, liabilities, damages, or expenses arising out of or in any way connected with the administration of the injection.I have read this waiver and fully understand its contents. I am aware that by signing this waiver, I am giving up certain legal rights, including the right to sue. Information Guide Before proceeding with the vitamin injection, please consider the following information: Purpose: Vitamin injections are administered to supplement essential nutrients that may be lacking in your diet or to provide a more direct route of absorption for certain vitamins and minerals. Benefits: The benefits of vitamin injections may include increased energy levels, improved mood, enhanced immune function, and better overall health and wellbeing. Types of Vitamin Injections: Common vitamin injections include Vitamin B12, Vitamin D, Vitamin C, and various combinations of vitamins and minerals tailored to individual needs. Administration: Vitamin injections are typically administered intramuscularly (into the muscle) or subcutaneously (under the skin) by a qualified healthcare professional. Precautions: While vitamin injections are generally considered safe, it's essential to disclose any pre-existing medical conditions, allergies, or medications you are taking to your healthcare provider before undergoing the procedure. Possible Side Effects: Some individuals may experience minor side effects such as bruising, swelling, or redness at the injection site. In rare cases, allergic reactions or infections may occur. Aftercare: Follow any post-injection instructions provided by your healthcare provider, such as avoiding strenuous activity, staying hydrated, and monitoring for any unusual symptoms. Consultation: If you have any questions or concerns about vitamin injections, don't hesitate to consult with your healthcare provider or the administering professional. By signing below, you acknowledge that you have read and understood the information provided in this guide and that you consent to proceed with the vitamin injection. You may need to click the submit button twice.