FOrms

Wellness Injection Form

Please complete this form prior to receiving a wellness injection at Etanah Medicine and Wellness.

First Name

Last Name

Phone

Birthday required

Do you have any known allergies to medications, vitamins, preservatives, or injectable ingredients? If Yes, please explain below. If No please write NA.

Are you currently pregnant, breastfeeding, or trying to become pregnant? Please write Yes and explain, or if No write No.

Have you ever had an allergic or adverse reaction to an injecton, IV treatment, vitamin, or medication? Please indicate yes, no and if yes explain.

Do you currently have a fever, acute illness, active infection, or feel signicfily unwell today? If yes explain if no write no.

Are you currently taking prescrition medications, over-the-counter medications, or supplements that your provider should know about? If yes please explain, if no write no.

Thanks for submitting!

Any other medical informaiton you believe your provider should know before administering this injection? If no, write no.

ABOUT WELLNESS INJECTIONS

Wellness injections may contain vitamins, minerals, amino acids, antioxidants, or other nutrients administered by intramuscular or subcutaneous injection. The specific treatment, ingredients, purpose, dose, route, expected benefits, and relevant risks will be reviewed with me before treatment. I understand that individual results vary and no benefit is guaranteed.

BENEFITS, RISKS + ALTERNATIVES

Potential benefits vary by treatment and may include nutritional supplementation or support for general wellness, energy, metabolism, or antioxidant status.

Possible risks include pain, redness, swelling, bruising or bleeding at the injection site; headache, dizziness, nausea, flushing or fainting; infection; nerve, blood vessel, or tissue injury; and allergic reactions, including rare serious reactions such as anaphylaxis. Other unexpected reactions may occur, and specific ingredients may carry additional risks.

Alternatives include declining treatment, oral supplementation or dietary modification when appropriate, and other medical treatment as recommended by my healthcare provider.

CONSENT

I understand the treatment’s purpose, potential benefits, risks, side effects, and alternatives.

I have provided accurate information regarding my medical history, medications, allergies, pregnancy status, and previous reactions.

I understand results are not guaranteed and I may decline treatment before it is administered.

I have had the opportunity to ask questions and authorize Etanah Medicine & Wellness and its appropriately licensed healthcare providers to administer the selected injection.

EMERGENCY CARE

If I experience an adverse reaction, I authorize reasonable measures necessary for my immediate safety, including emergency medical services when appropriate

PATIENT ACKNOWLEDGMENT: By signing below, I confirm that I have read and understood this consent, that my questions have been addressed, and that I voluntarily consent to treatment.

Your Signature

Talia Sessel, FNP-C

Serving aventura & Greater miami &
Colorado and Michigan

Schedule a Consult

FOrms

Wellness Injection Form

Talia Sessel, FNP-C

Serving aventura & Greater miami & Colorado and Michigan

Schedule a Consult

FOrms

Wellness Injection Form

Serving aventura & Greater miami &
Colorado and Michigan