Champion Health and Wellness Clinics

4295 San Felipe St., Ste. 235 Houston TX 77027

Patient Consent Form

IM Injections Onboarding Process

step 1


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B12 Injections Informed Consent Patient

Vitamin B-12 helps maintain optimal health and has been shown to be beneficial in helping to reduce fatigue, improve memory, and maintain a healthy body weight. It is what your body uses to help create energy, which is one of the reasons people feel more energized when they take B12./

All medications and supplements have potential side effects, including B12. Most people tolerate B12 without issue, side effects are rare. Potential common B12 side effects include but are not limited to: mild diarrhea, upset stomach, nausea, pain at the injection site, swelling, headache and joint pain.

You acknowledge:
1. That if I begin to have side effects, I will contact CHAMPION HEALTH AND WELLNESS CLINICS, Cynthia Champion MSN APRN FNP-C 281-501-0611 immediately and notify them of what is happening.

2. I understand that although rare, vitamin B12 injections can result in serious side effects.If these occur, you should follow up with a medical provider or go to the emergency department immediately. Uncommon and dangerous side effects include: rapid heartbeat, chest pain, flushed face, muscle cramps, weakness, difficulty breathing and swallowing, dizziness, confusion, rapid weight gain, feeling of tightness in the chest, hives and rashes, shortness of breath when there is no physical exertion and unusual wheezing and coughing.

3. Before starting vitamin B12 injections I agree to make my CHAMPION HEALTH AND WELLNESS CLINICS, Cynthia Champion aware if I have any of these conditions: Leber’s Disease, liver disease, kidney disease, iron deficiency, folic acid deficiency, receiving any treatment or taking any medication that has an effect on bone marrow, or drug/supplement allergies.

4. I understand that there could be interactions with B12 and certain medications/supplements.

5. The use of B12 on a weekly to biweekly basis without a documented B12 deficiency is considered off label use and has not been FDA approved for increasing energy levels and weight loss.

6. Caution is advised while taking B12 if you have a sulfa allergy.

By signing below, I acknowledge that I have read the informed consent and agree to the treatment with its associated risks. I hereby give consent for B12 injections. I agree to inform my medical provider immediately if I have any side effects. I hereby release CHAMPION HEALTH AND WELLNESS CLINICS, Cynthia Champion and the person injecting the B12 of any damages or liability if anything was to occur.