LipoB Injection Treatment Consent

This consent form confirms that I have been satisfactorily informed and educated about LipoB intramuscular injections, including their purpose, expected benefits, limitations, risks, alternatives, possible adverse effects, and post-care responsibilities. This information allows me to make a voluntary and informed decision regarding whether to proceed with this treatment.

Nature of LipoB Injections

I understand that LipoB injections are administered intramuscularly and are intended to support metabolic function, energy levels, and overall wellness.

I understand that the procedure involves inserting a needle into a muscle to deliver the injection.

Treatment Course & Expectations

I understand that multiple treatments may be recommended depending on my health status and any underlying vitamin, mineral, or nutrient deficiencies.

I understand that vitamin B12–containing injections are most effective when administered at regular intervals, commonly once weekly for four weeks followed by monthly maintenance, and that injection schedules may be individualized.

I understand that maintaining a healthy lifestyle, proper nutrition, and regular exercise will help sustain and enhance treatment benefits.

Treatment Variability & No Guarantee

I understand that individual results vary and that responses to treatment cannot be predicted.

I understand that although positive results are expected, medicine is not an exact science, and no guarantee or assurance can be made regarding treatment outcomes.

Alternatives

I understand that alternatives to intramuscular LipoB injections may include lifestyle modification, dietary changes, oral supplementation, or no treatment at all. These alternatives have been discussed with my provider.

Medical History & Contraindications

I agree to disclose all current medical conditions, allergies, and medications prior to treatment.

I understand that sensitivity or allergy to cobalt or vitamin B12 is a contraindication to this treatment.

I understand that individuals with chronic liver or kidney disease, Leber’s disease, abnormal red blood cells (including megaloblastic anemia), or certain metabolic disorders may not be appropriate candidates for frequent B12-containing injections.

I deny that I am currently pregnant, attempting to become pregnant, or breastfeeding. I understand that the safety of LipoB injections during pregnancy and breastfeeding has not been established. If uncertain, I will request pregnancy testing prior to treatment.

Risks & Possible Complications

I understand that intramuscular injections involve risks, which may include but are not limited to discomfort at the injection site, bruising, tenderness, inflammation, scarring, allergic reactions, infection, and delayed reactions.

I understand that severe allergic reactions, including anaphylaxis, cardiac complications, or other serious adverse events are rare but possible.

I understand that unknown or unforeseen side effects may also occur.

Delayed Reactions & Patient Responsibility

I understand that patient experiences vary and that delayed reactions may occur. I agree to notify AI Wellness Center of Excellence promptly if I experience any unusual, worsening, or concerning symptoms.

Pre- and Post-Treatment Instructions

I understand that the procedure, including its benefits, risks, alternatives, and possible complications, has been explained to me.

I acknowledge that I have received counseling regarding pre- and post-treatment care and agree to follow all instructions provided.

Provider Authorization

I authorize Dr. Gideon Kwok, D.O., and/or trained and qualified medical associates at AI Wellness Center of Excellence to perform LipoB intramuscular injections on me.

I acknowledge that I have had the opportunity to inquire about the qualifications and experience of the provider administering my treatment and that I am satisfied.

Voluntary Consent

I confirm that my consent is voluntary, informed, and freely given, and that I agree to notify the clinic of any changes in my medical history or concerns related to treatment.

Final Acknowledgment

I certify that I have read, understood, and agree to the contents of this LipoB Injection Treatment Consent. This document supersedes all prior verbal or written disclosures, and I freely consent to LipoB injections.