Injectable Vitamins

Consent Form

Patient name: DOB: Date:

What are your main complaints?

Do you have MTHFR mutation?

Have you had Vitamin B complex injections before? Where?

Benefits of Vitamin B Complex

Vitamin B Complex helps maintain good health and has been shown to be beneficial in helping to: Reduce stress, fatigue, improve memory and cardiovascular health, and maintain a good body weight. It can also assist the body in converting proteins, fats and carbohydrates into energy and is necessary for healthy skin and eyes. Vitamin B Complex is comprised up of specific amounts of the eight subtypes of vitamin B along with other neutralizing components which are proven to boost energy levels and vitality.

Dr Hoppe’s Vitamin Injectable: (mark one)

Ultra-Fat Burner:L-Carnitine 500mg/ml,Methionine 25mg/ml, Inositol 50mg/ml, Choline Chloride 50mg/ml, Folic Acid 1mg/ml, Niacinamide 5gm/ml, B Complex 100 0.1 ml, preserved with 0.9% Benzyl Alcohol, Sodium hydroxide and hydrochloric acid to adjust pH 7-7.4

Clean and Lean: Methionine 25mg/ml, Inositol 50mg/ml, Choline Chloride 50mg/ml, Folic Acid 1mg/ml, Niacinamide 5gm/ml, B Complex 100 0.1 ml, preserved with 0.9% Benzyl Alcohol, Sodium hydroxide and hydrochloric acid to adjust pH 7-7.4.

Happy Hoppe: B1 (Thiamine) 25mg/ml, B2 (Riboflavin) 2mg/ml, B3 (Niacin) 25mg/ml, B5 (Pantothenic acid) 5mg/ml, B6 (Pyridoxine) 50mg/ml, B12 (Methyl cobalamin) 1100mcg/ml, B9 (folic Acid) 1mg/ml

Treatments: Can be once a month, once a week, or twice a week and will be determined by the provider.

Possible side effects and Contraindications:

  • Some redness and swelling at the injection site may occur. This should start to get better with forty-eight (48) hours.
  • In rare cases, Vitamin injections can cause dizziness, heart palpitations, chest pain, muscle cramps, restlessness, diarrhea, peripheral vascular thrombosis, itching, transitory exanthema, urticaria (hives), and feelings of swelling of the whole body.
  • I understand that certain herbal products, vitamins, minerals, nutritional supplements, prescription and non-prescription medications may result in side effects when they interact with the B Complex Injection.
  • Niacin (B3) can cause flushing and itchiness. Consuming alcohol along with niacin might make the flushing and itching worse. Taking niacin (B3) and using a nicotine patch can increase the possibility of becoming flushed and dizzy.
  • People with chronic liver and/or kidney dysfunction should not take frequent B12 injections; therefore, we ask that you provide us with the most recent copy of lab work, which reflects liver and kidney function.
  • Interactions with drugs: Anticholinergic drugs interact with RIBOFLAVIN (VITAMIN B2), medications used for lowering cholesterol (Statins) interact with NIACIN (VITAMIN B3), chloramphenicol can impede on the red blood cell producing properties of B12.
  • Other drugs that decrease or reduce absorption of B12: antibiotics, cobalt irradiation, colchicine, colestipol, H2-blockers, metformin, nicotine, birth control pills, potassium chloride, proton pump inhibitors such as Prevacid, Losec, Aciphex, Pantaloc, and Zidovudine.
  • Amiodarone (Cordarone) interacts with PYRIDOXINE (VITAMIN B6)

Informed Consent Treatment:

I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. By signing below, I acknowledge that I have read the foregoing informed consent and agree to the treatment with its associated risks. I hereby give consent to perform this and all subsequent B Complex Injections with the above understood. I hereby release Diana Hoppe, MD, & the person injecting the B Complex, and the facility from liability associated with this procedure.

Patient SignatureDate