Informed Consent for B12 Vitamins and and other Lipotropic Injection Therapy
This document is intended to serve as confirmation of informed consent for injection therapy at Sei Tu Bella Aesthetics.
I have informed Sei Tu Bella Aesthetics of any known allergies to drugs or other substances, or of any past reactions to injections. I have informed the providers of all my medical conditions and current medications. I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and to give my informed consent.
I am aware that other unforeseeable complications could occur. I do not expect Sei Tu Bella Aesthetics to anticipate and or explain all risks and possible complications. I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered. I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance. When purchasing or receiving Vitamin B 12, MICC, TRI-IMMUNE, or other Lipotropic Injections from Sei Tu Bella Aesthetics, you agree to the
I have given my consent to injection therapy with any different or further procedures which, Sei Tu Bella Aesthetics, may be indicated.The procedure involves inserting a needle into various areas of the body and injecting vitamins and other homeopathic remedies.
Risks of injection therapies include but are not limited to: Occasionally to commonly Discomfort, severe pain, bruising, inflammation, injury, and numbness at the site of injection. Fatigue, dizziness, or light-head feeling after the injections. Fainting or loss of consciousness during the procedure.
Extremely rare: Severe allergic reaction, anaphylaxis, infection. I understand that some of the treatment injections may include a combination of the
• I understand the information provided on this form and agree to the foregoing.
• The procedure(s) set forth above has been adequately explained to me
• I have received all the information and explanation I desire concerning the
I authorize and consent to the performance of the procedure(s). I understand that the treatment may involve risks of complication or injury from both known and unknown causes, and I freely assume those risks. Prior to receiving treatment, I have been candid in revealing any condition that may have a bearing on this procedure.
I consent and authorize Sei Tu Bella Aesthetics, LLC, and its affiliates to perform the procedure listed on me. I certify that I have read this entire informed consent and I understand and agree to the information provided in the form. My questions regarding the procedure have been answered satisfactorily. I hereby release Heather Merlo, APRN, FNP-C, Medical Director Dr. Fernando Jara, Sei Tu Bella Aesthetics LLC from all liabilities associated with this procedure.
This consent is valid for all of my treatments in the future as well.