Vitamin B12 Injection Form Contact Patient InformationHealth History Book an appointmentConsent Welcome to our Vitamin B12 Injection FormPlease fill out this form so your clinician can know a little more about youFirst NameLast NameEmailPhone/MobileAddressAddress Line 1CityPostcodeCountryUnited KingdomUnited Kingdom (UK)Date of birth Sex at birth Male FemalePreviousNextWhat 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 NoPlease describeAre you allergic to the active ingredients of b12 injections: Hydroxocobalamin or Cobalt Yes No Don't knowPlease describeAre you currently pregnant, breastfeeding, or trying to get pregnant? Pregnant Trying to get pregnant Breastfeeding None of the aboveHave you had a b12 injection in the last 28 days Yes NoHave you ever suffered from any heart problems or diseases? Yes NoAre you currently on any medications? Yes NoPlease list which one(s)PreviousNextSelect Appointment Date & TimePreviousNextInformation 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 Previous Submit Form
