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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
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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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