B12 Intramuscular Injection Intake Form
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2B12 INTRAMUSCULAR INJECTION INTAKE FORM
Patient Information:
Name: ________________________________________ Date: __________________
Address: _____________________________________________________________
City: __________________ State: ____________ ZIP Code: _______________
Phone: _________________(H) __________________(C) _________________(other)
Date of Birth: _________________________(D/M/Y) Age: ______ Sex: M / F
(circle one)
Occupation: _______________________ Email address: _______________________
Would you like to receive our quarterly newsletter via email? Yes______
No______
In case of emergency, who should we contact: ________________________________
What are your main complaints?___________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Please check if you have any of the following:
□ Fatigue
□ Low depressed mood
□ Pernicious Anemia
□ Weight issues
□ Irritability/moodiness
□ Pregnant /trying to be pregnant
□ Heart Disease
□ Diabetes
□ Memory Loss/Alzheimer’s
□ Sleep disorders
□ Osteoporosis
□ Tendonitis
□ Asthma
□ Allergies
□ Immunosuppression
□ Thyroid disorders □ IBS/Inflammatory Bowels □ Numbness or tingling of body
How did you learn about this service?
□ Already a Client
□ Advertisement
□ Website
□ Living Social
□ Web Search
□ Referred by: ___________________________________________________
□ Walk-In/Sign
□ Other: ________________________________________________________
If you purchased a package: An injection will be deducted from your package for every
missed appointment or late cancellation (less than 24 hours notice).
Informed Consent for Treatment I have read the information regarding risks and benefits of B12 on page 2
and have had a chance to ask questions on the treatment. I understand the possible complications of
injection therapy are minor bruising and bleeding at injected sites, dizziness, headaches and possible
fainting from the site of blood. I understand clearly that there may be a slight chance for sensitivities and
reactions to the B12 solution. I hereby release Dr. Brenden Cochran and Dr. Susan H. Mueller from all
liabilities regarding my treatment with B12 injections.
___________________________________________________________________
Patient Signature
Date (dd/mm/yy)
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