Champion Health and Wellness Clinics

4295 San Felipe St., Ste. 235 Houston TX 77027
281-501-0611

Patient Consent Form

Phentermine Onboarding Process

step 5

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"*" indicates required fields

INJECTION CONSENT FORM

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 in regard to the results and length of time it lasts.

As with any treatment there can be some risk. The following is the list of possible risk with injections: Pain or bruising, redness, bleeding at the injection site (these are usually minimal and dissipate in minimal amount of time). Some people may experience allergic reaction to the injections.

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

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

I had been given the opportunity to have all of my questions answered.

I will inform my practitioner of any changes in my medical history, current medications, and/or any changes relevant to this procedure prior any further treatments.

I, have read and understand the ingredients of the injections being administered to me and I consent to treatment. I further acknowledge that I am taking this injection(s) of my own accord. I agree to release the facility and the medical practitioner from any liability arising from the procedure.

This consent is ongoing for this and all future injection treatments.

Name*