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Vitamin B12 Injection Consent Form

This is an informed consent form that has been prepared to help inform you of the potential benefits and risks of vitamin B12 injection. It is important that you read this information carefully and discuss fully with your practitioner before proceeding with treatment.

It is also important that you take as much time as you need to consider the treatment carefully, weighing up all your options before reaching an informed decision. It is essential that you are aware of your right to have a second opinion and you are encouraged to ask any questions that come to mind throughout the entirety of the process.
Vitamin B12 is also known as Cobalamin, it is a water-soluble vitamin essential for both fatty acid and amino metabolism as well as DNA synthesis. It is vital for the normal functioning of the nervous system, myelin sheath production and red blood cell maturation and development.
Vitamin B12 deficiency has a broad presentation including fatigue, anemia, multiple neurological and psychiatric signs and symptoms.
Replacement of vitamin B12 is in the form of Hydroxocobalamin given by intramuscular injection. The prophylactic dose for prevention of B12 deficiency is 1mg every 2-3 months by intramuscular injection. The other form of B12 injection is called (MIC-B12) which is vitamin B12 combined with Methionine, Inositol and Choline, given as a combination injection intramuscular. The MIC-B12 combination is targeted to try and facilitate weight loss together with a healthy diet and regular physical exercise.
An intramuscular injection of B12 is given into the Deltoid muscle in the side of the upper arm. The procedure is very quick, you may feel a short, sharp pain during the injection.
It is important that you see your doctor/GP if you suspect or display symptoms of B12 deficiency. It is important also to not exceed the recommended doses of B12. If your B12 injector is from a non-medical background, then your B12 injection must be prescribed by a doctor or prescribing nurse practitioner on a separate consultation appointment. A blood test to check your blood B12 level can be taken by your doctor/GP, the prescribing clinician may want to know your B12 level before going ahead with B12 prescription for you. If you have a known vitamin B12 deficiency, then investigation of the cause and replacement should be conducted by your doctor/GP only.
RISKS AND SIDE EFFECTS: You must be aware of the following side effects of intramuscular vitamin B12 injection before commencing treatment. You must fully discuss any questions with your practitioner and prescriber before proceeding.
I understand the common side effects are pain during injection, redness, swelling and soreness around the injection site lasting up to a few days. You may also experience some bruising around the injection site also. Some people can faint or feel faint with needles and injections, it is important to tell your practitioner as soon as possible if you feel unwell during or after the injection.
Uncommon side effects include dizziness, headache, nausea, vomiting, hot flushes, skin reactions, chills, tremor, insomnia.
Rare side effects include cardiac arrhythmias, thrombocytosis, hypokalemia (low blood potassium level). There is also a rare risk of allergic reaction or anaphylactic reaction to the B12 injection. In the event of anaphylaxis or any serious side effects, you would require emergency medical attention.
I have been advised of the relevant information associated with this treatment and I confirm that I fully understand this advice. This includes advice about:
- the aims/motivations for having the procedure and the desired outcome
- the risks inherent in the procedure
- the risks inherent in refusing the procedure
- the risks specific to me
- the expected benefits of the treatment
- the potential disadvantages of the treatment
- alternative procedures and their pros and cons - including the option of no treatment at all
- any uncertainties about and the likelihood of success of the procedure
- any follow-up treatment that may be required
I request treatment with B12 or MIC-B12. The injection of B12 or MICB12 has been explained to me and my questions regarding such treatment have been answered to my satisfaction. The information given to me has been in clear terms and I understand the risks, benefits, possible side effects and complications of the treatment. I certify that I am in good health. I have read the information about the B-12 injection.
I have been asked what information I want and would need in order to make an informed decision. I have been given the opportunity to discuss my desired outcome fully in order for me to make an informed decision.
I certify that I have read the above consent and that I fully understand it. I have been given ample opportunity for discussion and all my questions have been answered to my satisfaction. No new information has become available that affects my decision to have the treatment or my decision to consent. I hereby consent to this procedure. This constitutes the full disclosure and supersedes any previous verbal or written disclosures.
Date / Time
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Please follow the aftercare advice for intramuscular Vitamin B12 injection.

• You may experience some mild tenderness, redness and swelling around the
injection site. These effects will usually resolve within 48 hours but may last
longer in some cases.
• You may experience some bruising around the injection site, this will resolve
naturally but may take 1-2 weeks to resolve.

• If you experience any discomfort afterwards you can take a simple over the
counter painkiller such as paracetamol.
• You must seek medical attention and contact your practitioner if you develop
any signs or symptoms of skin infection around the injection site. Infection can
present as hot, red shiny skin, there may be pus formation and you may have
a fever or feel generally unwell.
• You must contact your practitioner as soon as possible if you experience
any other unwanted side effects after having the injection.
• Seek medical attention if you feel unwell or experience any significant
side effects following the injection.
• Seek emergency medical attention in the rare event that you experience
any severe allergy signs or features of anaphylaxis after the injection.
These may include rash, facial swelling and breathing difficulties.
It is essential that you have read all of the information available. Once you have
read and understood all of the below, please sign the declaration at the bottom of
this form. Please do let your practitioner know if you have any questions or if you
do not understand any of the aftercare instructions provided below.
I confirm that I have read and understood all the information on this Form and that
I have been given the opportunity to ask any questions that have come to mind