Irie Natural Center for Health
6625 S Rural Rd #103
Tempe, AZ 85283
Dr. Sonya Johnson, NMD
Informed Consent For Treatment - Consent for B12 Injection, Consent for MIC-B12 Injection
I hereby request and consent to receive medical care by Sonya Johnson, NMD or other medical associates (medical assistants, nurses) who now or in the future may treat me while working at or associated with or serving as back-up for the above named doctor, whether signatories to this form or not. By signing this form, I hereby am giving consent for B12/Mic Injections. In the event an adverse reaction may occur from receiving B12/Mic Injections, the signature below releases any liability and damages, should this occur, to Sonya Johnson, NMD, and treating staff. Further, this intake form is not a replacement for the clinic's standardized Intake Form which is used for office visit purposes. I have read, or have had read to me, the above information and I consent.
● I UNDERSTAND THE RECOMMENDED DOSE FOR B12 IS 1-2 ml INTRAMUSCULAR WEEKLY. (A DOSE OF 1 ml MAY BE GIVEN AT THE BEGINNING OF THE WEEK AND A SECOND DOSE OF 1 ml AT THE END OF THE WEEK)
● I UNDERSTAND THE RECOMMENDED DOSE FOR MIC-B12-B Complex IS 1-4 ml INTRAMUSCULAR WEEKLY.
● POSSIBLE SIDE EFFECTS CAN INCLUDE IRRITATION AT THE SITE, INFECTION, BRUISING, AND TENDERNESS AT THE INJECTION SITE.
● I CERTIFY THAT I DO NOT HAVE AN ALLERGY TO SULFA.
● I CERTIFY THAT I DO NOT HAVE A LIVER OR KIDNEY IMPAIRMENT THAT I AM AWARE OF.
I have also had an opportunity to ask questions about the consent's content and by voluntarily signing below I agree to the above-named procedures.
IRIE NATURAL CENTER FOR HEALTH