Vitamin injections Consent

1. Purpose

WildBerryMD offers compounded MIC-B12 vitamin injections as an elective, self-pay wellness service. MIC-B12 is a compounded preparation that may contain methionine, inositol, choline, and vitamin B12 (cyanocobalamin).

Eligibility for these vitamin injections is determined following an individualized medical review of the health information, medical history, medications, allergies, and other information you provide to a licensed WildBerryMD clinician (“clinician”).

2. Compounded Medication Disclosure

I understand that:

• My medication is a compounded prescription prepared by a properly licensed compounding pharmacy.
• Compounded medications are not approved by the U.S. Food and Drug Administration (FDA) and have not been evaluated by the FDA for safety, effectiveness, or quality.
• These vitamin injections are prescribed based on the independent clinical judgment of my clinician following a review of my submitted health information.

3. Potential Benefits

The ingredients in MIC-B12 participate in normal metabolic and physiologic processes. When recommended by my clinician, compounded MIC-B12 injections are intended to support general wellness and may help support:

• Healthy energy metabolism
• Normal vitamin B12 levels in appropriate individuals
• Normal fat metabolism as part of a healthy diet and regular physical activity
• Healthy metabolic function
• Overall wellness

These vitamin injections are intended to complement, not replace, a healthy diet, regular physical activity, and other healthy lifestyle practices.

Individual responses vary, and no specific outcome or benefit is guaranteed. These vitamin injections are not intended to diagnose, treat, cure, or prevent any disease and should not replace routine medical care or the advice of your healthcare providers.

4. Who Should Not Receive MIC-B12 Injections

MIC-B12 injections may not be appropriate for everyone. Before receiving these vitamin injections, I agree to inform my clinician if I:

• Am pregnant, planning to become pregnant, or breastfeeding.
• Have a known allergy or sensitivity to vitamin B12, cobalt, methionine, inositol, choline, or any ingredient contained in the compounded medication.
• Have Leber’s hereditary optic neuropathy (Leber’s disease).
• Have significant kidney disease or liver disease.
• Have an active infection or other serious medical condition.
• Have a history of severe allergic reactions (anaphylaxis) to injectable medications.
• Am receiving treatment that affects my bone marrow.
• Develop any new medical condition or begin taking any new prescription medication before or during use of these vitamin injections.

I understand that my clinician may determine that these vitamin injections are not appropriate for me or may recommend delaying or declining a prescription based on my medical review.

5. Risks and Possible Side Effects

Possible side effects may include:

• Pain, redness, bruising, bleeding, swelling, or infection at the injection site
• Nausea
• Upset stomach
• Headache
• Dizziness
• Flushing
• Fatigue
• Mild diarrhea

Rare but potentially serious side effects may include:

• Allergic reactions
• Chest pain
• Rapid heartbeat
• Difficulty breathing or swallowing
• Severe rash or hives
• Swelling of the face, lips, tongue, or throat
• Anaphylaxis

6. When to Contact WildBerryMD

I agree to stop using my MIC-B12 injections and promptly contact my clinician if I:

• Experience concerning side effects.
• Develop a new medical condition.
• Become pregnant or begin breastfeeding.
• Begin taking a new prescription medication.
• Have questions regarding the safe use of these vitamin injections.

If I experience symptoms of a medical emergency, including difficulty breathing, chest pain, severe allergic reaction, or swelling of the face, lips, tongue, or throat, I understand that I should call 911 or seek immediate emergency medical care.

7. Patient Responsibilities

I agree to:

• Provide complete, accurate, and current medical information.
• Notify my clinician of any changes to my medical history, medications, allergies, pregnancy status, or health conditions.
• Follow all instructions regarding the use and administration of my MIC-B12 injections.
• I understand how to properly prepare and administer my MIC-B12 injections or have received adequate instruction regarding their proper administration. I understand that I am responsible for following all instructions provided by WildBerryMD and my dispensing pharmacy.
• I understand that my prescribed MIC-B12 injections are intended solely for my personal use. I will not share, sell, transfer, or allow any other person to use my medication or injection supplies.
• Store my medication according to pharmacy instructions.
• Continue routine medical care with my primary care provider and other healthcare professionals, as appropriate.

8. Payment and Refund Policy

I understand and acknowledge that:

• MIC-B12 injections are provided as a self-pay wellness service.
• Payment is required before my prescription is processed or dispensed.
• Due to the customized nature of compounded medications and applicable pharmacy regulations, all sales are final.
• Once my prescription has been submitted to the compounding pharmacy, MIC-B12 injections are non-refundable, non-returnable, and non-exchangeable.

9. Safe Disposal of Sharps (Arizona)

I understand that I am responsible for the safe handling and disposal of all needles, syringes, and other sharps used with my MIC-B12 injections. I agree to:

• Place used needles and syringes immediately into a puncture-resistant, leak-resistant sharps container or heavy-duty plastic container with a secure lid (such as an empty laundry detergent bottle).
• Keep the sharps container out of reach of children and pets.
• Never place loose needles or syringes into household trash or recycling.
• Securely seal and dispose of the container in accordance with applicable Arizona and local disposal guidelines.

10. Telehealth Acknowledgment

I understand that:

• My care is provided through telehealth.
• Recommendations are based upon the health information I provide during my medical review.
• No in-person physical examination may be performed.
• WildBerryMD is not an emergency medical provider and does not replace my primary care provider.
• In the event of a medical emergency, I will call 911 or seek immediate medical attention.

11. Voluntary Participation

I understand that participation in this wellness program is voluntary. I may discontinue receiving MIC-B12 injections at any time after notifying my clinician. WildBerryMD does not guarantee any specific results or outcomes.

12. Release and Indemnification

To the fullest extent permitted by applicable law, I agree to release, indemnify, defend, and hold harmless WildBerryMD, its owners, clinicians, employees, contractors, affiliated pharmacies, successors, and agents from any claims, damages, liabilities, losses, costs, or expenses, including reasonable attorneys’ fees, arising from:

• My failure to provide complete or accurate medical information.
• My failure to follow medical instructions.
• My misuse or improper administration of my prescribed MIC-B12 injections.
• My failure to seek appropriate medical care when necessary.
• My voluntary participation in this elective wellness service.

except to the extent such claims arise from WildBerryMD’s gross negligence, willful misconduct, or any liability that cannot legally be waived under applicable law.

13. Patient Consent

By signing below, I acknowledge that:

• I have read and understand this informed consent.
• I have had the opportunity to ask questions and receive satisfactory answers.
• I understand the potential risks and limitations associated with compounded MIC-B12 injections.
• I understand that compounded medications are not FDA-approved and have not been evaluated by the FDA for safety, effectiveness, or quality.
• I understand that individual results vary and are not guaranteed.
• I voluntarily consent to receive compounded MIC-B12 injections if my clinician determines they are appropriate following my individualized medical review.
• I agree that my electronic signature has the same legal effect as my handwritten signature.