Shot Registration & Consent

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Date
MM slash DD slash YYYY
Name
First Last
Email*
Enter Email Confirm Email
Phone*
optional
Choose Injection*
- Vitamin B-12
- Lipo-Release
- UNICORN
Consent*
I consent to a Vitamin injection.
I acknowledge that I have been informed and consent to the treatment with its associated risks. I hereby give consent to perform this and all subsequent Vitamin Injections with the above understood. I hereby release the doctor, the
person injecting the Vitamin Injection, and the facility from liability associated with this procedure.

Your email will not be shared, sold, published or spammed. Email is used to track patients and any needed correspondence.