Vitamin B12 Injection Form

Patient Information
Health History
Book an appointment
Consent

Welcome to our Vitamin B12 Injection Form

Please fill out this form so your clinician can know a little more about you

First Name

Last Name

Phone/Mobile

Address

Address Line 1

City

Postcode

Country

Date of birth

Sex at birth

Male

Female

What is your reason for requesting a vitamin b12 injection?

Diagnosed with anaemia/b12 deficiency

Reduce feelings of tiredness and fatigue

Following a diet that does not allow me to achieve the recommended levels of Vitamin B12

To boost my regular b12 levels for health reasons

Do you take any of the following supplements

Vitamin A

Vitamin C

Vitamin D

Vitamin E

Vitamin B12

Iron

Multivitamins

None of the above

Have you ever reacted to an injection?

Yes

Please describe

Are you allergic to the active ingredients of b12 injections: Hydroxocobalamin or Cobalt

Yes

Don't know

Please describe

Are you currently pregnant, breastfeeding, or trying to get pregnant?

Pregnant

Trying to get pregnant

Breastfeeding

None of the above

Have you had a b12 injection in the last 28 days

Yes

Have you ever suffered from any heart problems or diseases?

Yes

Are you currently on any medications?

Yes

Please list which one(s)

Select Appointment Date & Time

Information and Consent

I can confirm that:

The information that I provided is accurate and true to the best of my knowledge
I understand that I can not order b12 injections for another person

I have read the information regarding the benefits and risks of vitamin b12 and I consent to receiving this service

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