IM INJECTIONS INTAKE FORM

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IM INJECTIONS INFORMED CONSENT

THE PROCEDURE

The IM Therapy procedure involves inserting a needle into the muscle and injecting vitamins, minerals and glutathione. The procedure involves inserting a needle generally into the muscle of the thigh, shoulder, or upper buttocks. IM Therapy is a means to deliver vitamins, minerals and other nutrients to the body while avoiding the digestive process. This is helpful in many cases where patients are depleted of certain nutrients and is especially helpful in conditions of decreased intestinal absorption of nutrients.

POTENTIAL BENEFITS OF IM THERAPY (Depending on the substance(s) being injected. Such benefits include but are not limited to):

• Injection into the muscles and tissue is not affected by stomach or intestinal absorption disturbances and therefore is better absorbed by the body. This can be especially helpful for individuals with conditions such as decreased intestinal absorption of nutrients, achlorhydria, long-term PPI use, and pernicious anemia. • Higher doses of vitamins, minerals and other substances can be given than is possible by oral consumption and without intestinal irritation that can accompany doses given by mouth.

POTENTIAL SIDE AFFECTS & RISKS (Depending on the IM Therapy Solutions include but are not limited to):

Discomfort such as redness, bruising, swelling, burning, stinging, pain, and/or bleeding at the site of the injection. The redness and swelling may last up to a few days. • Infection at the site of the injection. • Injury to nerve and/or muscle at the site of the injection. • Sensitivities or allergic reactions to the injection solution such as, for example, reactions to cobalt and/or cobalamin in injections containing B12 or reactions to anesthetics in injections containing lidocaine/procaine. • Mild diarrhea, upset stomach, nausea, increased urination, itching, headache, joint pain, racing heart, dizziness or a feeling of light-headedness after injections depending on the substance(s) in the injection. • It has been reported that B12 can cause itching, and a feeling of swelling in the body. • In rare cases, severe allergic reaction and anaphylaxis to the injection solution.

CONTRAINDICATIONS (Depending on the IM Therapy Solution may include but are not limited to)

• Known liver and/or kidney dysfunction • Sensitivity to cobalt and/or cobalamin is a contraindication to injections containing B12. • Vitamin B12 is contraindicated in Leber’s disease, a hereditary optic nerve atrophic condition, as it can lead to blindness.

PAYMENT

I understand that this is an “elective” procedure and that payment is my responsibility and is expected at the time of treatment.

ALTERNATIVE PROCEDURES

Alternatives to the procedures and options that I have volunteered for have been fully explained to me.

IM INJECTIONS INFORMED CONSENT

PREGNANCY, ALLERGIES & NEUROLOGICAL DISEASE

I am not aware that I am pregnant and I am not trying to get pregnant, I am not lactating {nursing). I do not have any significant neurological disease including but not limited to Myasthenis Gravis, Multiple Sclerosis, Lambert-Eaton Syndrome, Amyotrophic Lateral Sclerosis {ALS), and Parkinson’s. I do not have any allergies to the toxin ingredients, or to human albumin.

PHOTO CONSENT

I give permission to take before and after photographs of my treatment to be used to monitor my treatment, training purposes, and advertising.

RIGHT TO DISCONTINUE TREATMENT

I understand that I have the right to discontinue treatment at any time.

RESULTS

No Guarantees: I understand that each patient responds differently to treatments and from one treatment to the next. I understand results are only temporary and regular dosing is necessary. I understand the length of time IM Therapy is needed for therapeutic benefit varies for each patient. I further understand that no guarantee can be made or is made by my Service Provider with respect to results and length of time required for IM Therapy benefit.

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