Vitamin B12 Patient Form

Please list all medications you are currently taking, if none please state "None"

Contra-Indications

Please Select Any Contra-Indications For Im Hydroxocobalamin B12 Injection That Apply To You

Indications

Please Select Any Indication For Im Hydroxocobalamin B12 Injection That Apply To You. If You Have No Symptoms Listed Below - Please Select ‘Other’ At The Bottom To Add Any Other Symptoms, Concerns That You Have And Reasons For Requesting Treatment (Such As Lack Of Energy/Trouble Sleeping Etc)

Verification

Please Check That All Information You Have Provided Above Is Correct And Enter Your Name And Tick The Consent Button As A Digital Signature