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b12 consultation form

First name

Surname

Date of birth

Email address

Mobile number

Address Line 1

Address Line 2

Town / City

Do you suffer from fatigue or weakness?

Yes

No

Postcode

Do you have difficulty concentrating or a poor memory?

Yes

no

Do you suffer from numbness or tingling feeling in your hands or feet?

Yes

No

Do you feel restless?

Yes

No

Do you suffer from low mood or depression?

Yes

No

Are u pregnant or breast feeding?

Yes

No

Your label Have you had B12 injection before?

Yes

No

Do you experience light headiness or dizziness?

Yes

No

Do you have low potassium Levels?

Yes

No

Do you suffer from any heart condition? or do you have a irregular or fast heartbeat?

Yes

No

Please consent to understanding the possible side effects

pain, swelling or itchy skin where your injection was given

Feeling or being sick (nausea or vomiting)

diarrhoera

headaches

feeling dizzy

hot flushes

Who is your practitioner?

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  - Sosum Skin Booster
  - Toskani
  - Chemical Peels
  - Chemical Peels
  - PDO Threads
  - PDO Threads
  - Fat Dissolvers
  - Deso face & body
  - lipolax
  - Aqualyx
  - celluerase
  - Strikecell
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