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Vitamins to Your Door Consult/Consent Form

This form will be sent to your provider for review.

If you are unsure about your vitamin choice(s), STOP HERE and select LET'S CHAT

What are your goals
Do you have any of the following conditions?
Are you taking any blood thinners?
Are you pregnant or breast feeding?
Do you drink alcohol?

WATCH MANDATORY HOW TO SELF-INJECTION VIDEO

I understand these injections are to be self injected in the frontal thigh area, as portrayed in the video (https://youtu.be/fMEZdNodGM0). I agree I will use the syringes and vitamins as directed.
I UNDERSTAND THIS IS A NON-REFUNDABLE PRODUCT AND CANNOT BE RETURNED. I AGREE TO THE REFUND POLICY. I authorize Anew Beauty Clinic to charge my credit card for agreed upon purchases. I understand that my information will be saved for future charges.
I acknowledge that I have received instructions and educational material for the administration of home injections. I acknowledge that the risks of injections has been discussed with me.
I agree to have on hand an epinephrine injector to use in case of a systemic reaction. I acknowledge that I have received instruction on its use and administration. I further understand that I must identify that the date of this medication is current
I understand that these risks include, but are not limited to, local reactions, rashes, bruises, etc. - I understand that if I elect to do self-administered injections or if another designated individual gives me the injection, I should be attended for at leat 30 minutes prior to medication administration
I understand that it is my responsibility to maintain follow up appointments with my provider at Anew Beauty Clinic as needed.
By signing this form, I assume full responsibility for receiving my injections and release ABC providers from any liability or responsibility for any reactions, conditions, self-injection procedures or injuries in conjunction with the injections.
Select an item ($)

Thanks for submitting!

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