B12 Consent


Information Vitamin B-12 

Vitamin B12 helps maintain good health and has been shown to be beneficial in helping to:  Reduce stress, fatigue, improve memory and cardiovascular health, and maintain a good body weight. It can also assist the body in converting proteins, fats and carbohydrates into energy and is necessary for healthy skin and eyes. B12 Injections are better absorbed by the body since they go directly into the blood stream. 

Side Effects 

Alternatives to B12 injections are Oral Vitamins, B12 Patch, Lozenges, Liquid drops and Nasal Spray B12 Injections common side effects include but are not limited to:1.Risks: I understand there is risk of mild diarrhoea, upset stomach, nausea, feeling of pain and a warm sensation at the site of the injection, a feeling, or a sense, of being swollen over the entire body, headache joint pain. I understand that although rare Vitamin B12 injections can result in serious side effects. Although this is a relatively rare occurrence, anyone taking vitamin B12 injections should be aware of the possibility. Uncommon side effects are much more serious than the common side effects of B12 injections, and such side effects should be reported to a physician to be evaluated for seriousness. Uncommon and dangerous side effects include: rapid heartbeat, chest pain, flushed face muscle, cramps and weakness difficulty breathing and swallowing dizziness confusion rapid weight gain, tight feelings in the chest, hives, skin rashes, shortness of breath when there is no physical exertion and unusual wheezing and coughing.

Disclaimer 

Before starting vitamin B12 injections I will make sure to tell my Physician if I am pregnant, lactating or have any of the following conditions. - Leber’s Disease, Kidney disease, Liver disease, An infection, Iron deficiency, Folic acid deficiency, Receiving any treatment that has an effect on bone marrow Taking any medication that has an effect on bone marrow An allergy to cobalt or any other medication, vitamin, dye, food or preservative

I understand that certain herbal products, vitamins, minerals, nutritional supplements, prescription, and non-prescription medications may result in side effects when they interact with the B12 Injection.

Treatments: Can be once a month, once a week, twice a week and will be determined by the provider.

I consent to acting as a model for the purpose of training (under supervision) in the administering of B12 Injection. The use and indications for the products that I will be treated with have been explained to me by the practitioner and I have had the opportunity to have all my questions answered to my satisfaction. I have answered the questions regarding my medical history to the best of my knowledge. 

Training course times may be delayed due to unforeseen circumstances.  It may take longer training the students or the student may need more support.  So please allow extra time in case this event occurs. Your full payment for your treatment as a model is non-refundable. If the circumstances occur outlined above and/or cancellation your payment is non-refundable. The full payment will be made prior to attending the training academy. 

Every procedure involves a certain amount of risk and it is important that you understand the risks involved.  An individual’s choice to undergo a procedure is based on the comparison of the risk to potential benefit. Although most patients do not experience these complications, you should discuss each of them with your practitioner to ensure you understand the risks. Potential complications and consequences of B12 injection outlined above

I consent to Ampika’s Aesthetics using photographs being stored on a training file and be used for social media purposes and/or video recordings including images of me both internally and externally to promote the Training Academy. These images could be used in print and digital media formats including print publications, websites, e-marketing, posters banners, advertising, film, social media, teaching and research purposes. I understand that images on websites can be viewed throughout the world and not just in the United Kingdom and that some overseas countries may not provide the same level of protection to the rights of individuals as EU/UK legislation provides. I understand that some images or recordings may be kept permanently once they are published. I have read and understand the conditions and consent to my images being used as described. 

I am signing to consent to my treatment being administered at Ampika’s Aesthetics. On behalf of the training academy Ampika’s Aesthetics - Ampika’s Hair Make Up and Beauty. You are agreeing to be a model and hold no responsibility towards Ampika’s Aesthetics for any procedures that may incur any personal dissatisfaction or cause of concern.

Any models wishing to seek any legal or liable action will not be permitted to do so once signing this disclaimer you are excepting full responsibility to allow a student to carry out your injectable treatments.

These Students who are responsible for carrying out the treatment under medical supervision, are not fully qualified to carry out B12 unassisted. Therefore, you understand the risk that this may pose. Any concerns must be addressed whilst you are present in the training academy. Whilst all the trainers accommodate you to ensure you are fully satisfied with your treatment, we are unable to rectify problems weeks after you have undergone the treatment. If there are any concerns, then please contact the training academy within 48 hours of treatment via email – [email protected].

I consent I have read and understood the after-care sheet which has been provided to me. By signing this form you have agreed to consent to adhere to our vaccination policy.

The information that I have given is correct to the best of my knowledge.

I have not knowingly withheld any medical information.

I consent to the treatment described.

 

 

 

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Signed by Ampika Pickston
Signed On: March 24, 2021

Signature Certificate
Document name: B12 Consent
lock iconUnique Document ID: 8f3c1756818ce428914ec0c13ab41ec9318156c4
Timestamp Audit
November 16, 2020 2:49 pm BSTB12 Consent Uploaded by Ampika Pickston - [email protected] IP 2a00:23c4:600b:6200:6d1f:26d0:f128:fda8
February 1, 2021 9:50 am BSTAmpika Aesthetics - [email protected] added by Ampika Pickston - [email protected] as a CC'd Recipient Ip: 2a00:23c4:600b:6200:c553:e3b7:94b6:6079
March 24, 2021 2:23 pm BSTAmpika Aesthetics - [email protected] added by Ampika Pickston - [email protected] as a CC'd Recipient Ip: 2a00:23c4:600b:6200:6d1f:26d0:f128:fda8