Vitamin Injection Consent
(Telehealth or Brick-and-Mortar)
Date: March 12, 2026
Patient Information
- Patient Name: {{patient_first_name}} {{patient_last_name}}
- Date of Birth: {{patient_birthdate}}
Allergy Information
Important: Any member with an allergy to sulfa or red dye cannot receive this shot, and should look for another option. Also included in a Buck Shot are: [specific ingredients to be listed]
Anyone with an allergy to red dye cannot receive this shot.
Post-Injection Monitoring
It is recommended that you wait 20-30 minutes after your first injection to notice any potential side effects. Side effects, if any, might include: [side effects to be listed]
Patient Authorization
I authorize my Provider to assist me in my wellness efforts. I understand it is my responsibility to follow all instructions carefully and report any significant medical problems that may be related to treatment (injection) as soon as reasonably possible.
Signatures
Patient Signature: _________________________ Date: March 12, 2026
Provider Signature: Date: March 12, 2026
Medical Services Provided by Primary Medical of KY, P.S.C., Elite Health Services, P.A., CO., Primary Medical of IN, P.C. 2025.04.21
Form Complete
Well done you did it! d 
